Prior Authorization
Aetna Prior Authorization for CPT 97597
Removal of dead tissue from open wound, first 20 sq cm or less · 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 selective debridement (97597). For chronic wounds (diabetic ulcers, venous ulcers, pressure injuries) with necrotic or devitalized tissue. Must have failed at least 30 days of standard wound care. Documentation must include wound measurements, wound bed description, and percentage of devitalized tissue. Vascular assessment required for lower extremity wounds.
Documentation checklist
- ✓Wound etiology and duration documentation
- ✓Wound measurements (L x W x D) and photographs
- ✓Wound bed description (necrotic, slough, granulation percentages)
- ✓Prior wound care treatments and duration
- ✓Vascular assessment for lower extremity wounds (ABI or vascular consult)
Submission channels
Phone
1-800-624-0756Fax
1-860-754-56702026 Medicare rate for CPT 97597
Office (non-facility)
$101.54
Facility
$31.06
Total RVUs (office)
3.04
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 97597 code page.
How to submit the PA
- 1Verify the requirement against the current clinical policy linked above.
- 2Gather documentation: Wound etiology and duration documentation, Wound measurements (L x W x D) and photographs, Wound bed description (necrotic, slough, granulation percentages)….
- 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 97597?
- Yes. Aetna requires prior authorization for CPT 97597 (Removal of dead tissue from open wound, first 20 sq cm or less) under Standard commercial plans per its published clinical policy.
- What documentation does Aetna require for CPT 97597?
- Wound etiology and duration documentation; Wound measurements (L x W x D) and photographs; Wound bed description (necrotic, slough, granulation percentages); Prior wound care treatments and duration; Vascular assessment for lower extremity wounds (ABI or vascular consult)
- How much does Medicare pay for CPT 97597 in 2026?
- In 2026, the national Medicare allowable for CPT 97597 is $101.54 in an office setting and $31.06 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.
- What if Aetna denies the PA for CPT 97597?
- 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 97597 prior authorization by payer
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