Prior Authorization
Humana Prior Authorization for CPT 97161
Physical therapy evaluation, low complexity, typically 20 minutes · Standard commercial plans
Source
Humana Commercial Preauthorization and Notification List (July 2024)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
Humana requires prior authorization for outpatient physical therapy evaluation (97161). Must have physician referral with diagnosis. Low complexity evaluation for single body region with straightforward presentation. Treatment plan with measurable goals required. Medicare Advantage: subject to therapy cap with exceptions process for medical necessity above threshold.
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
1-800-444-9137Fax
1-877-418-05062026 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). Humana'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 fax, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Humana require prior authorization for CPT 97161?
- Yes. Humana 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 Humana 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 Humana are typically negotiated against this benchmark.
- What if Humana 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 Humana PA lookups
CPT 97161 prior authorization by payer
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