Prior Authorization
Aetna Prior Authorization for CPT 81163
Genetic and molecular testing including BRCA gene testing · Standard commercial plans
Source
Aetna Participating Provider Precertification List 2026 (Updated May 1, 2026)Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.
Clinical criteria
Aetna lists this code under Special programs: Breast and ovarian cancer susceptibility screening (BRCA), with listed contracted genetic testing providers and online medical precertification form instructions. The Medicare Advantage-only BRCA code is intentionally excluded from this commercial capture. Evidence: PDF p.31, Special programs, Breast and ovarian cancer susceptibility screening.
Documentation checklist
- ✓Completed BRCA medical precertification request
- ✓Medical records requested for genetic testing review
2026 Medicare rate for CPT 81163
CPT 81163 is not priced under the 2026 Medicare Physician Fee Schedule (status X) — drugs/biologicals price under ASP and lab tests under the CLFS. See the CPT 81163 code page for pricing detail.
How to submit the PA
- 1Verify the requirement against the current clinical policy linked above.
- 2Gather documentation: Completed BRCA medical precertification request, Medical records requested for genetic testing review.
- 3Submit via the payer's provider portal or designated PA channel.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Aetna require prior authorization for CPT 81163?
- Yes. Aetna requires prior authorization for CPT 81163 (Genetic and molecular testing including BRCA gene testing) under Standard commercial plans per its published clinical policy.
- What documentation does Aetna require for CPT 81163?
- Completed BRCA medical precertification request; Medical records requested for genetic testing review
- What if Aetna denies the PA for CPT 81163?
- Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.
Other Aetna PA lookups
CPT 81163 prior authorization by payer
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