Prior Authorization
Aetna Prior Authorization for CPT 97161
Physical therapy evaluation, low complexity, typically 20 minutes · 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 outpatient PT evaluation. Physician prescription required with ICD-10 diagnosis and description of functional impairment. Low complexity evaluation (97161) appropriate for single body region with straightforward clinical presentation. Treatment plan must include objective findings, functional goals, and frequency/duration.
Documentation checklist
- ✓Physician referral or prescription with ICD-10 diagnosis
- ✓Description of functional limitations
- ✓Treatment plan with measurable goals and expected duration
- ✓Prior treatment history if applicable
Submission channels
Phone
1-800-624-0756Fax
1-860-754-56702026 Medicare rate for CPT 97161
Office (non-facility)
$97.86
Facility
$97.86
Total RVUs (office)
2.93
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 97161 code page.
How to submit the PA
- 1Verify the requirement against the current clinical policy linked above.
- 2Gather documentation: Physician referral or prescription with ICD-10 diagnosis, Description of functional limitations, Treatment plan with measurable goals and expected duration….
- 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 97161?
- Yes. Aetna requires prior authorization for CPT 97161 (Physical therapy evaluation, low complexity, typically 20 minutes) under Standard commercial plans per its published clinical policy.
- What documentation does Aetna require for CPT 97161?
- Physician referral or prescription with ICD-10 diagnosis; Description of functional limitations; Treatment plan with measurable goals and expected duration; Prior treatment history if applicable
- How much does Medicare pay for CPT 97161 in 2026?
- In 2026, the national Medicare allowable for CPT 97161 is $97.86 in an office setting and $97.86 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.
- What if Aetna denies the PA for CPT 97161?
- 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 97161 prior authorization by payer
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