Does C1772 require prior authorization?

Yes, C1772 requires prior authorization (high confidence). Code explicitly requires prior authorization.

`C1772`, Infusion pump, programmable (implantable)

HCPCS/CPT

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Clinical documentation of failure of or intolerance to conservative treatments (e.g., systemic medications, physical therapy, behavioral health interventions).
Records demonstrating compliance with prior treatment attempts for the condition.
Psychological evaluation report documenting that mental health is not a major contributor to the pain condition.
Documentation showing systemic opioid dose was reduced/weaned by at least 50% prior to trial.

Long-term management of select patients with intractable pain using an implanted intrathecal or epidural drug delivery system that delivers medication directly into the spinal fluid.
Preliminary trial of epidural or intrathecal opioid for chronic intractable pain of malignant origin when: inadequate response to or intolerable side effects from noninvasive methods of pain control (e.g., systemic opioids); life expectancy > 3 months; and no evidence of epidural metastatic lesion(s) or tumor encroachment of the thecal sac on imaging.
Preliminary trial of epidural or intrathecal opioid for chronic intractable pain of nonmalignant origin (e.g., failed back surgery syndrome, complex regional pain syndrome) when: the pathology for the pain has been identified and life expectancy > 3 months.
Chronic pain refractory to or unable to tolerate conservative treatments (systemic pharmacotherapy, physical therapy, behavioral health for pain, and other appropriate nonsurgical treatments).
Member has demonstrated compliance with previous attempts to treat the condition.
Psychological evaluation confirms that a mental health condition is not a major contributor to the chronic pain symptoms.

AMBETTER-CP.MP.173, Implantable Intrathecal or Epidural Pain Pump

EVICORE-HPLAN-CIGNA-1815296EE67F, Cigna Comprehensive Code List - Effective 03/07/2026

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

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