Does Anthem require prior authorization for CPT 43239?

No. Anthem does not list CPT 43239 on its current prior-authorization list for Standard commercial plans.

What documentation does Anthem require for CPT 43239?

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 43239 in 2026?

In 2026, the national Medicare allowable for CPT 43239 is $418.85 in an office setting and $123.58 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 43239?

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

Anthem Prior Authorization for CPT 43239

EGD (upper gastrointestinal) · Standard commercial plans

No PA requiredApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

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

Anthem does not require prior authorization for diagnostic EGD with biopsy for standard indications. Covered for dysphagia, GERD refractory to PPI therapy, GI bleeding evaluation, Barrett's surveillance, and suspected upper GI malignancy.

2026 Medicare rate for CPT 43239

Office (non-facility)

$418.85

Facility

$123.58

Total RVUs (office)

12.54

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 43239 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 Anthem require prior authorization for CPT 43239?: No. Anthem does not list CPT 43239 on its current prior-authorization list for Standard commercial plans.
What documentation does Anthem require for CPT 43239?: 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 43239 in 2026?: In 2026, the national Medicare allowable for CPT 43239 is $418.85 in an office setting and $123.58 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 43239?: 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 Anthem PA lookups

CPT 17110 CPT 45380 CPT 45378 CPT 11042 CPT 36415 CPT 20610 CPT 62323 CPT 43235

All Anthem prior-authorization requirements →

CPT 43239 prior authorization by payer

Blue Cross Blue Shield Cigna Aetna Humana TRICARE Medicare

No PA needed — is Anthem paying CPT 43239 correctly?

When prior auth isn't the blocker, underpayment is. Check 43239 against the 2026 Medicare benchmark and run a free leak check — no signup.

Check 43239 payment in Ask D3 See the 43239 Medicare rate