Humana Prior Authorization for CPT 45380

Clinical criteria

Humana does not require prior authorization for colonoscopy with biopsy. Screening covered per USPSTF and ACS guidelines (age 45+). Diagnostic colonoscopy covered for GI bleeding, anemia, change in bowel habits, and polyp surveillance.

2026 Medicare rate for CPT 45380

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Humana's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 45380 code page.

How to submit the PA

1. 1Verify the requirement against the current clinical policy linked above.
2. 2Gather patient history, prior conservative treatment, and clinical justification.
3. 3Submit via the payer's provider portal or designated PA channel.
4. 4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Humana require prior authorization for CPT 45380?

No. Humana does not list CPT 45380 on its current prior-authorization list for Standard commercial plans.

What documentation does Humana require for CPT 45380?

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 45380 in 2026?

In 2026, the national Medicare allowable for CPT 45380 is $479.97 in an office setting and $177.69 in a facility. Commercial allowables for Humana are typically negotiated against this benchmark.

What if Humana denies the PA for CPT 45380?

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 Humana PA lookups

CPT 45380 prior authorization by payer