Prior Authorization
Humana Prior Authorization for CPT 97597
Removal of dead tissue from open wound, first 20 sq cm or less · 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 wound debridement (97597). For chronic wounds with devitalized tissue: diabetic foot ulcers, venous stasis ulcers, pressure ulcers stage 3-4. Must have failed 30+ days standard wound care. Document wound measurements, wound bed status, and healing trajectory at each visit. Lower extremity wounds require vascular assessment.
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
1-800-444-9137Fax
1-877-418-05062026 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). Humana'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 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 97597?
- Yes. Humana 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 Humana 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 Humana are typically negotiated against this benchmark.
- What if Humana 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 Humana PA lookups
CPT 97597 prior authorization by payer
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