Does E0786 require prior authorization?

Yes, E0786 requires prior authorization (high confidence). Code explicitly requires prior authorization.

`E0786`, Implantable programmable infusion pump, replacement (excludes implantable

HCPCS/CPT

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

When billing J7999-KD, enter the name and total dose (mg or mcg) of each drug in Box 19 of the CMS-1500 or the appropriate electronic comment loop; if Box 19 cannot accommodate all information, attach the details to the paper claim.
If a portion of a single-dose vial is not used, submit the HCPCS code for the drug on a separate claim line and append modifier JW to indicate discarded/unused portion.
Separate payment may be made for pump refilling and/or adjustments; submit these services using the appropriate drug refill or maintenance CPT/HCPCS code that accurately describes the service rendered.
Compounded drugs are priced by the A/B MAC contractor by multiplying the contractor's price per mcg or mg by the total number of mcg or mg of each drug used; a pharmacy compounding fee may be allowed in addition to the calculated drug amount.

Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.
Durable medical equipment, orthotics, and prosthetics that are necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a physical deficit.
Equipment expected to make a meaningful contribution to treatment of the patient’s illness or injury or to improvement of a malformed body member.

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_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

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

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