Aetna Outpatient Physical Therapy prior authorization requirements (2026)
What Aetna generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Commercial plans. Yes. Aetna generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
Medical-necessity criteria Aetna generally applies
Outpatient physical therapy requires medical necessity for skilled care: an objective functional deficit, an individualized plan of care with measurable, time-bound goals, interventions that require the skills of a licensed therapist, and periodic re-evaluation documenting progress or the continued need for skilled intervention. Continuation or extension of visits requires documentation of ongoing medical necessity — measurable functional limitations, the skilled nature of the interventions, and the clinical rationale for continued therapy. For chronic neurological conditions such as spinal cord injury, document the need for skilled therapy to maintain function and prevent deterioration, secondary complications, or loss of function.
Source
General commercial outpatient-PT medical-necessity criteria (verify payer-specific clinical policy / visit limits; many plans apply InterQual or MCG). For Medicare Advantage products the Jimmo maintenance standard applies. Last verified 2026-06-10.
Frequently asked questions
Does Aetna require prior authorization for Outpatient Physical Therapy?
Yes. Aetna generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
What does Aetna require to approve Outpatient Physical Therapy?
Outpatient physical therapy requires medical necessity for skilled care: an objective functional deficit, an individualized plan of care with measurable, time-bound goals, interventions that require the skills of a licensed therapist, and periodic re-evaluation documenting progress or the continued need for skilled intervention. Continuation or extension of visits requires documentation of ongoing… Always confirm against the current Aetna policy.
How long does a Aetna prior authorization take?
Turnaround varies by plan and submission method. Check the Aetna portal for current timeframes.
Submitting Outpatient Physical Therapy to Aetna?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.