Does C1767 require prior authorization?

Yes, C1767 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

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`C1767`, Generator, neurostimulator (implantable), non-rechargeable

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Documentation Required

Voiding diaries documenting baseline and test-stimulation outcomes are required to measure the ≥50% improvement for urinary indications.
For fecal incontinence, documentation must show frequency (>2 incontinent episodes/week), duration (>6 months or >12 months after vaginal childbirth), and failure or intolerance of conventional therapies.
A percutaneous test stimulation report documenting at least 50% sustained (>1 week) improvement is required to support permanent implantation for fecal incontinence.
Medical records must document that the patient is refractory to conventional therapy (behavioral, pharmacologic and/or surgical) for urinary indications and is an appropriate surgical candidate able to undergo anesthesia.
Records must document that the condition is not related to excluded causes (anorectal malformation, pelvic radiation sequelae, active anal abscess/fistula, chronic IBD, neurologic causes) when claiming coverage for fecal incontinence.
Medical record documentation of prior conventional therapies tried and failed (behavioral, pharmacologic and/or surgical) must be provided for urinary indications.

Key Coverage Criteria

Sacral nerve stimulation (SNS) is covered for urinary urge incontinence.
SNS is covered for urgency-frequency syndrome (urinary urgency-frequency).
SNS is covered for urinary retention.
Both a temporary test stimulation and subsequent permanent implantation of an implanted sacral electrode array are covered for appropriate candidates.
SNS is covered for fecal incontinence when all fecal-specific criteria are met (see limitations/frequency): chronic fecal incontinence with >2 incontinent episodes/week and duration >6 months or >12 months after vaginal childbirth.
Coverage for fecal incontinence requires documented failure or intolerance to conventional therapy (e.g., dietary modification, bulking agents, pharmacologic treatment).

20 Active Policies

PALMETTO-JJ-L39543, Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

PALMETTO-JM-L39543, Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

ANTHEM-SURG.00129, Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

ANTHEM-SURG.00158, Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

ANTHEM-SURG.00112, Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)

ANTHEM-CG-SURG-70, Gastric Electrical Stimulation

ANTHEM-CG-SURG-120, Vagus Nerve Stimulation

ANTHEM-CG-SURG-95, Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence

EVICORE-HPLAN-CIGNA-AFCE721BA4F3, Cigna Comprehensive Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA-844835841DE9, Cigna Commercial Interventional Pain Management Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA-47DEF0053A7B, Cigna Commercial Sleep Management Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA_MEDICARE-47F76AA38AE6, Cigna Medicare Advantage Interventional Pain Management Code List - Effective 01/01/2025

ANTHEM-SURG.00026, Deep Brain, Cortical, and Cerebellar Stimulation

HUMANA-OBSTRUCTIVE-SLEEP-APNEA-AND-OTHER-SLEEP-RELATED-BREATHING-DISORDERS-SURGICAL-TREATMENTS-MA, Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments

CIGNA-0391, Diaphragmatic/Phrenic Nerve Stimulation

A53359, Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence

A55835, Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence

A59332, Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments

AMBETTER-CP.MP.40, Gastric Electrical Stimulation

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Ask Backwork about documentation requirements, denial risks, or coverage in your state.

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C1767, Generator, neurostimulator (implantable), non-rechargeable

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Documentation Required

Voiding diaries documenting baseline and test-stimulation outcomes are required to measure the ≥50% improvement for urinary indications.
For fecal incontinence, documentation must show frequency (>2 incontinent episodes/week), duration (>6 months or >12 months after vaginal childbirth), and failure or intolerance of conventional therapies.
A percutaneous test stimulation report documenting at least 50% sustained (>1 week) improvement is required to support permanent implantation for fecal incontinence.
Medical records must document that the patient is refractory to conventional therapy (behavioral, pharmacologic and/or surgical) for urinary indications and is an appropriate surgical candidate able to undergo anesthesia.
Records must document that the condition is not related to excluded causes (anorectal malformation, pelvic radiation sequelae, active anal abscess/fistula, chronic IBD, neurologic causes) when claiming coverage for fecal incontinence.
Medical record documentation of prior conventional therapies tried and failed (behavioral, pharmacologic and/or surgical) must be provided for urinary indications.

Key Coverage Criteria

Sacral nerve stimulation (SNS) is covered for urinary urge incontinence.
SNS is covered for urgency-frequency syndrome (urinary urgency-frequency).
SNS is covered for urinary retention.
Both a temporary test stimulation and subsequent permanent implantation of an implanted sacral electrode array are covered for appropriate candidates.
SNS is covered for fecal incontinence when all fecal-specific criteria are met (see limitations/frequency): chronic fecal incontinence with >2 incontinent episodes/week and duration >6 months or >12 months after vaginal childbirth.
Coverage for fecal incontinence requires documented failure or intolerance to conventional therapy (e.g., dietary modification, bulking agents, pharmacologic treatment).

20 Active Policies

PALMETTO-JJ-L39543, Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

PALMETTO-JM-L39543, Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

ANTHEM-SURG.00129, Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

ANTHEM-SURG.00158, Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

ANTHEM-SURG.00112, Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)

ANTHEM-CG-SURG-70, Gastric Electrical Stimulation

ANTHEM-CG-SURG-120, Vagus Nerve Stimulation

ANTHEM-CG-SURG-95, Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence

EVICORE-HPLAN-CIGNA-AFCE721BA4F3, Cigna Comprehensive Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA-844835841DE9, Cigna Commercial Interventional Pain Management Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA-47DEF0053A7B, Cigna Commercial Sleep Management Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA_MEDICARE-47F76AA38AE6, Cigna Medicare Advantage Interventional Pain Management Code List - Effective 01/01/2025

ANTHEM-SURG.00026, Deep Brain, Cortical, and Cerebellar Stimulation

HUMANA-OBSTRUCTIVE-SLEEP-APNEA-AND-OTHER-SLEEP-RELATED-BREATHING-DISORDERS-SURGICAL-TREATMENTS-MA, Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments

CIGNA-0391, Diaphragmatic/Phrenic Nerve Stimulation

A53359, Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence

A55835, Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence

A59332, Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence

AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments

AMBETTER-CP.MP.40, Gastric Electrical Stimulation

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about C1767 Sign up free

`C1767`, Generator, neurostimulator (implantable), non-rechargeable

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`C1767`, Generator, neurostimulator (implantable), non-rechargeable

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

C1767, Generator, neurostimulator (implantable), non-rechargeable

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

C1767, Generator, neurostimulator (implantable), non-rechargeable

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`C1767`, Generator, neurostimulator (implantable), non-rechargeable

`C1767`, Generator, neurostimulator (implantable), non-rechargeable