Aetna prior authorization and CPT code lookup, page 4
CPT code lookup
Each row is one code from the participating-provider precertification list. This is not a coding dictionary, and it is not a coverage decision. The description is the service name on that list.
Participating-provider outpatient list
Inpatient, emergency, and observation settings are outside this outpatient list. This page does not publish a determination for those settings.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 15825 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 15826 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 15828 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 17380 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 19318 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 21270 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 30400 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 30410 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 30420 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 30430 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 30435 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 30450 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 53430 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54125 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54400 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54401 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54405 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54406 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54408 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54410 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54411 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54415 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54416 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54417 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54520 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54660 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 54690 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 55175 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 55180 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 56625 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 56800 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 56810 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 57106 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 57107 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 57110 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 57111 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 57291 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 57292 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58150 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58180 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58260 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58262 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58275 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58280 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58285 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58290 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58291 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58541 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58542 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
| 58543 | Gender affirmation surgery | Participating provider precertification list for Aetna, Pg 9 Original policy |
Aetna precertification list
The participating-provider examples point at the official list. Open the list itself for the current file, including its effective date.
Plan and setting exceptions
Student Health and Allina Health / Aetna are separate from the participating-provider rows above.
Prior authorization forms
| Product or plan | Benefit | Route |
|---|---|---|
| Use the plan named on the official form page | Medical and pharmacy forms are listed by Aetna | Aetna health care professional forms |
This page does not reproduce a form and does not list a fax number that was not read from the form page.