Does C1787 require prior authorization?

Yes, C1787 requires prior authorization (high confidence). Code explicitly requires prior authorization.

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`C1787`, Patient programmer, neurostimulator

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Documentation Required

No explicit documentation requirements or a 'Documentation Requirements' section is stated in the CPB.
Phrases in the CPB that describe trial/assessment approaches and could be relevant to clinical documentation (extracted verbatim): ""'Successful' means a pain reduction of more than 50 % as assessed with a visual analog scale (VAS).""
Phrases in the CPB that describe pre/intra/post-operative procedures (extracted verbatim) which may be used clinically: "computer-aided neuro-navigation techniques and magnetic resonance imaging (MRI) images are used to guide implantation of electrode(s); and a second operation is performed for implantation of a neurostimulator if stimulation of the motor cortex is successful in alleviating the patient's pain."
Other trial/test phrases appearing in the CPB (from cited studies) that could be used as clinical evidence though not stated as policy requirements: "A test trial of minimum 1 week including double-blind testing was conducted", "trial periods of stimulation", "functional imaging guidance", "intra-operative somato-sensory evoked potentials (SSEPs) and direct stimulation were used to confirm the target and final placement of the electrode", and documentation of VAS or other pain scores pre- and post-stimulation.
Pain assessment documentation: baseline and follow-up pain scores using validated instruments (e.g., visual analog scale [VAS], McGill Pain Questionnaire, Brief Pain Inventory, medication quantification scale [MQS], sickness impact profile, QOL measures)
Programming and re-programming records (voltage, frequency, pulse width) and records of any adverse events including seizures

Key Coverage Criteria

Pain related to paraplegia / post-paraplegia pain (limited data; some improvement reported in small series)
Complex regional pain syndrome (CRPS) — discussed as experimental in guidelines; case report of combined SCS+MCS as rescue therapy
Pain related to intercostal herpes zoster (single-case reported improvement)
Chronic refractory pain conditions (general) — MCS has been used to treat various chronic refractory pain conditions (text: "Motor cortex stimulation (MCS) has been used to treat various chronic refractory pain conditions such as trigeminal neuralgia, post-stroke pain (PSP), and other nerve/brain injury pain syndromes.")
Trigeminal neuropathic pain / trigeminal neuralgia (TNP / TN) (multiple studies cited reporting use and outcomes)
Post-stroke pain (central post-stroke pain, PSP)

20 Active Policies

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

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

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

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

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

AETNA-CPB-0755, Motor Cortex Stimulation

AETNA-CPB-0362, Spasticity Management

AETNA-CPB-0374, Trigeminal Neuralgia: Treatments

AMBETTER-CP.MP.180, Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

BCBSIL-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions

BCBSIL-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation

BCBSMT-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions

BCBSMT-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation

BCBSNM-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions

BCBSNM-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation

BCBSOK-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions

BCBSOK-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation

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C1787, Patient programmer, neurostimulator