What documentation does Anthem require for CPT 97110?

Part of authorized PT treatment plan; Exercise specifics (type, sets, reps, resistance); Patient response and tolerance; Progress toward functional goals

How much does Medicare pay for CPT 97110 in 2026?

In 2026, the national Medicare allowable for CPT 97110 is $29.06 in an office setting and $29.06 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 97110?

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 97110

Therapeutic exercises to build strength, flexibility, or endurance · Standard commercial plans

Prior authorization 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 covers therapeutic exercises (97110) as part of authorized PT plan. Must be skilled therapy with documented medical necessity. Each session must include specific exercises, patient performance, and progress toward functional goals. Not covered for general conditioning or wellness exercise.

Documentation checklist

✓Part of authorized PT treatment plan
✓Exercise specifics (type, sets, reps, resistance)
✓Patient response and tolerance
✓Progress toward functional goals

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 97110

Office (non-facility)

$29.06

Facility

$29.06

Total RVUs (office)

0.87

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 97110 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Part of authorized PT treatment plan, Exercise specifics (type, sets, reps, resistance), Patient response and tolerance….
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 97110?: Yes. Anthem requires prior authorization for CPT 97110 (Therapeutic exercises to build strength, flexibility, or endurance) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 97110?: Part of authorized PT treatment plan; Exercise specifics (type, sets, reps, resistance); Patient response and tolerance; Progress toward functional goals
How much does Medicare pay for CPT 97110 in 2026?: In 2026, the national Medicare allowable for CPT 97110 is $29.06 in an office setting and $29.06 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 97110?: 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 90834 CPT 90837 CPT 90792 CPT 90847 CPT 90791 CPT 90832 CPT 97161 CPT 93000

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CPT 97110 prior authorization by payer

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