Does Anthem require prior authorization for CPT 97597?

Yes. Anthem 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 Anthem 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 Anthem are typically negotiated against this benchmark.

What if Anthem 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.

Prior Authorization

Anthem Prior Authorization for CPT 97597

Removal of dead tissue from open wound, first 20 sq cm or less · 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 selective wound debridement. Chronic wounds (diabetic, venous, pressure stage 3-4) with necrotic tissue after failed standard wound care (30+ days). Each visit must document wound measurements, bed description, and evidence of healing progress. Vascular assessment for lower extremity wounds. Re-authorization for ongoing treatment.

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

1-800-274-7767

2026 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). Anthem'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 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 97597?: Yes. Anthem 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 Anthem 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 Anthem are typically negotiated against this benchmark.
What if Anthem 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 Anthem PA lookups

CPT 90834 CPT 90837 CPT 90792 CPT 90847 CPT 90791 CPT 90832 CPT 97161 CPT 93000

All Anthem prior-authorization requirements →

CPT 97597 prior authorization by payer

Blue Cross Blue Shield Cigna Aetna Humana TRICARE Medicare

Draft the Anthem PA request for CPT 97597 — free

Ask D3 builds a payer-ready prior-authorization request with the right criteria language and documentation — backed by CMS, Medicare, and major-payer data. No signup.

Draft the 97597 PA in Ask D3 Look up another payer or code