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, SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
ANTHEM-SURG.00026, SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
ANTHEM-SURG.00158, SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
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
CARELON-sleep-disorder-management-2024-10-20-updated-2025-07-01-for-anthem-bcbs-ohio-medicaid-and-regence-only-deferred-to-2025-12-01, Sleep Disorder Management
BCBSOK-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
CARELON-sleep-disorder-management-2025-11-15-uc, Sleep Disorder Management
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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