What documentation does Anthem 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 Anthem are typically negotiated against this benchmark.

What if Anthem 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.

Prior Authorization

Anthem Prior Authorization for CPT 97161

Physical therapy evaluation, low complexity, typically 20 minutes · 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 requires prior authorization for outpatient PT via AIM Specialty Health. Physician referral with diagnosis and functional limitation description required. PT evaluation complexity level (97161 low, 97162 moderate, 97163 high) must be supported by documentation. Initial authorization covers evaluation and initial treatment block.

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

1-800-274-7767

2026 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). Anthem'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 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 97161?: Yes. Anthem 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 Anthem 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 Anthem are typically negotiated against this benchmark.
What if Anthem 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 Anthem PA lookups

CPT 90834 CPT 90837 CPT 90792 CPT 90847 CPT 90791 CPT 90832 CPT 93000 CPT 90846

All Anthem prior-authorization requirements →

CPT 97161 prior authorization by payer

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