Does Aetna require prior authorization for CPT 99214?

No. Aetna does not list CPT 99214 on its current prior-authorization list for Standard commercial plans.

What documentation does Aetna require for CPT 99214?

Documentation requirements vary by case. Standard items include clinical notes, imaging or test results, history of conservative treatment, and a clear statement of medical necessity.

How much does Medicare pay for CPT 99214 in 2026?

In 2026, the national Medicare allowable for CPT 99214 is $135.61 in an office setting and $84.50 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.

What if Aetna denies the PA for CPT 99214?

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.

Prior Authorization

Aetna Prior Authorization for CPT 99214

Office visit, established patient, moderate complexity · Standard commercial plans

No PA requiredState-specific policyLast updated March 17, 2026 · Reviewed by the D3rx Clinical Billing Team

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

Standard office visits do not require prior authorization.

2026 Medicare rate for CPT 99214

Office (non-facility)

$135.61

Facility

$84.50

Total RVUs (office)

4.06

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 99214 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather patient history, prior conservative treatment, and clinical justification.
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 99214?: No. Aetna does not list CPT 99214 on its current prior-authorization list for Standard commercial plans.
What documentation does Aetna require for CPT 99214?: Documentation requirements vary by case. Standard items include clinical notes, imaging or test results, history of conservative treatment, and a clear statement of medical necessity.
How much does Medicare pay for CPT 99214 in 2026?: In 2026, the national Medicare allowable for CPT 99214 is $135.61 in an office setting and $84.50 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.
What if Aetna denies the PA for CPT 99214?: 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 99213 CPT 99490 CPT 99215 CPT 99232 CPT 99203 CPT 99233 CPT 99202 CPT 99211

All Aetna prior-authorization requirements →

CPT 99214 prior authorization by payer

Blue Cross Blue Shield Cigna Humana TRICARE Medicare Anthem

No PA needed — is Aetna paying CPT 99214 correctly?

When prior auth isn't the blocker, underpayment is. Check 99214 against the 2026 Medicare benchmark and run a free leak check — no signup.

Check 99214 payment in Ask D3 See the 99214 Medicare rate