Aetna prior authorization and CPT code lookup, page 8

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

Prior authorization codes
Code	Description	Source
77523	Proton beam radiotherapy Also see Special programs: Radiation oncology	Participating provider precertification list for Aetna, Pg 11 Original policy
77525	Proton beam radiotherapy Also see Special programs: Radiation oncology	Participating provider precertification list for Aetna, Pg 11 Original policy
23470	Shoulder arthroplasty, including revision procedures	Participating provider precertification list for Aetna, Pg 11 Original policy
23472	Shoulder arthroplasty, including revision procedures	Participating provider precertification list for Aetna, Pg 11 Original policy
23473	Shoulder arthroplasty, including revision procedures	Participating provider precertification list for Aetna, Pg 11 Original policy
23474	Shoulder arthroplasty, including revision procedures	Participating provider precertification list for Aetna, Pg 11 Original policy
15820	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
15821	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
15822	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
15823	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
67900	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
67901	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
67902	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
67903	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
67904	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
67906	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
67908	Reconstructive or other procedures that may be considered cosmetic: Blepharoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
19355	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19340	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19342	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19350	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19357	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19364	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19370	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19371	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19380	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19396	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
S2066	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
S2067	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
S2068	Reconstructive or other procedures that may be considered cosmetic: Breast reconstruction/breast enlargement*	Participating provider precertification list for Aetna, Pg 11 Original policy
19316	Reconstructive or other procedures that may be considered cosmetic: Breast reduction/mammoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
19318	Reconstructive or other procedures that may be considered cosmetic: Breast reduction/mammoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
19325	Reconstructive or other procedures that may be considered cosmetic: Breast reduction/mammoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
19328	Reconstructive or other procedures that may be considered cosmetic: Breast reduction/mammoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
19330	Reconstructive or other procedures that may be considered cosmetic: Breast reduction/mammoplasty*	Participating provider precertification list for Aetna, Pg 11 Original policy
15830	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15832	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15833	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15834	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15835	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15836	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15837	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15838	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15839	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
15847	Reconstructive or other procedures that may be considered cosmetic: Excision of excessive skin due to weight loss*	Participating provider precertification list for Aetna, Pg 11 Original policy
43631	Reconstructive or other procedures that may be considered cosmetic: Gastroplasty/gastric bypass	Participating provider precertification list for Aetna, Pg 11 Original policy
43632	Reconstructive or other procedures that may be considered cosmetic: Gastroplasty/gastric bypass	Participating provider precertification list for Aetna, Pg 11 Original policy
43633	Reconstructive or other procedures that may be considered cosmetic: Gastroplasty/gastric bypass	Participating provider precertification list for Aetna, Pg 11 Original policy
43634	Reconstructive or other procedures that may be considered cosmetic: Gastroplasty/gastric bypass	Participating provider precertification list for Aetna, Pg 11 Original policy
43644	Reconstructive or other procedures that may be considered cosmetic: Gastroplasty/gastric bypass	Participating provider precertification list for Aetna, Pg 11 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.

Aetna participating provider precertification list

Aetna precertification lists

Plan and setting exceptions

Student Health and Allina Health / Aetna are separate from the participating-provider rows above.

Prior authorization forms

Official Aetna form route
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.