Prior Authorization
Aetna Prior Authorization for CPT 91110
Capsule endoscopy · 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 requires precertification for capsule endoscopy. Covered for obscure GI bleeding after negative bidirectional endoscopy, suspected Crohn's disease when other modalities are inconclusive, small bowel tumor evaluation, and polyposis syndrome surveillance. Patency capsule recommended before study if stricture is suspected. Not covered for known Crohn's with documented stricture.
Documentation checklist
- ✓EGD and colonoscopy reports
- ✓Clinical notes with bleeding history
- ✓Lab results
- ✓Small bowel imaging if obtained
Submission channels
Phone
1-800-624-0756Fax
1-860-754-56702026 Medicare rate for CPT 91110
Office (non-facility)
$802.29
Facility
$802.29
Total RVUs (office)
24.02
Conversion factor
$33.4009
National Medicare Physician Fee Schedule amounts (GPCI 1.0). Aetna's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 91110 code page.
How to submit the PA
- 1Verify the requirement against the current clinical policy linked above.
- 2Gather documentation: EGD and colonoscopy reports, Clinical notes with bleeding history, Lab results….
- 3Submit via phone or fax, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Aetna require prior authorization for CPT 91110?
- Yes. Aetna requires prior authorization for CPT 91110 (Capsule endoscopy) under Standard commercial plans per its published clinical policy.
- What documentation does Aetna require for CPT 91110?
- EGD and colonoscopy reports; Clinical notes with bleeding history; Lab results; Small bowel imaging if obtained
- How much does Medicare pay for CPT 91110 in 2026?
- In 2026, the national Medicare allowable for CPT 91110 is $802.29 in an office setting and $802.29 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.
- What if Aetna denies the PA for CPT 91110?
- 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 91110 prior authorization by payer
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