C1767 Generator, neuro non-rechargGenerator, neurostimulator (implantable), non-rechargeable
28 of 28 payer prior-auth lists that name C1767 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, Blue Shield of California, CarePlus Health Plans, Cigna, HealthSpring, Humana, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) | |
| Blue Shield of California | Blue Shield Medicare | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield Medicare | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2016 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2016 | Master Precertification List (For Health Care Providers) |
| Cigna | Musculoskeletal (MSK) - Pain Management | All | prior auth required | Crossover code: MSK Pain Management / Sleep Management | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs |
| Cigna | Musculoskeletal (MSK) - Pain Management | All | prior auth required | Crossover code: MSK Pain Management / Sleep Management | Mar 7, 2026 | Cigna Commercial Prior Authorization Procedure Code List: Musculoskeletal - Interventional Pain Management |
| Cigna | Musculoskeletal (MSK) - Pain Management | All | prior auth required | Crossover code: MSK Pain Management / Sleep Management | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs |
| Cigna | Musculoskeletal (MSK) - Pain Management | All | prior auth required | Crossover code: MSK Pain Management / Sleep Management | Mar 7, 2026 | Cigna Commercial Prior Authorization Procedure Code List: Sleep Management |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2025 | 2026 Q4 Prior Authorization List | |
| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth required | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List | |
| Humana | Humana D-SNP (FL) | FL | prior auth required | Jan 1, 2027 | 1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List | |
| Humana | Humana D-SNP (IL) | IL | prior auth required | Jan 1, 2027 | Humana Dual Fully Integrated Illinois Prior Authorization and Notification List | |
| Humana | Humana D-SNP (IN) | IN | prior auth required | Jan 1, 2027 | *New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List | |
| Humana | Humana D-SNP (MI) | MI | prior auth required | Jan 1, 2027 | 1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List | |
| Humana | Humana D-SNP (SC) | SC | prior auth required | Jan 1, 2027 | Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List | |
| Humana | Humana D-SNP (VA) | VA | prior auth required | Jan 1, 2027 | Virginia Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | VA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) | |
| Humana | Humana MA and D-SNP | All | prior auth required | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List | |
| Humana | Humana Puerto Rico MA and Dual Medicare-Medicaid | PR | prior auth required | Nov 3, 2025 | Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification | |
| Humana | Oak Street Health | All | prior auth required | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management | ||
| UnitedHealthcare Community Plan | UnitedHealthcare Connected (Texas MMP) | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |
C1767 appears in 62 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Shield of California, BlueCross BlueShield of South Carolina, Capital Blue Cross, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Acute Ischemic Stroke Treatments (0789) Cerebrolysin, Transdermal glyceryl trinitrate, Statins (e.g. simvastatin) | not covered | Nov 19, 2025 | payer document |
| Aetna | Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments (0788) | not covered | Nov 19, 2025 | payer document |
| Aetna | Deep Brain Stimulation (0208) | covered if criteria are met | Mar 27, 2026 | payer document |
| Aetna | Diabetic Neuropathy: Selected Treatments (0729) | covered if criteria are met | Feb 24, 2026 | payer document |
| Aetna | Eating Disorders (0511) | not covered | Aug 4, 2026 | payer document |
| Aetna | Epilepsy Surgery (0394) | covered if criteria are met | Jun 23, 2026 | payer document |
| Aetna | Fecal Incontinence (0611) Acticon neosphincter | covered if criteria are met | Sep 23, 2026 | payer document |
| Aetna | Gastric Pacing / Electrical Stimulation and Gastroesophageal Per Oral Endoscopic Myotomy (0678) | covered if criteria are met | Oct 7, 2025 | payer document |
| Aetna | Headaches: Invasive Procedures (0707) | not covered | Jul 23, 2026 | payer document |
| Aetna | Huntington's Disease (0614) | not covered | Sep 24, 2026 | payer document |
| Aetna | Motor Cortex Stimulation (0755) | not covered | Feb 24, 2026 | payer document |
| Aetna | NeuroControl Freehand System (0378) | covered if criteria are met | May 26, 2026 | payer document |
| Aetna | Obstructive Sleep Apnea in Adults (0004) | covered if criteria are met | Oct 6, 2026 | payer document |
| Aetna | Obstructive Sleep Apnea in Children (0752) | covered if criteria are met | Oct 30, 2025 | payer document |
| Aetna | Parkinson's Disease (0307) | not covered | Feb 24, 2026 | payer document |
| Aetna | Spasticity Management (0362) | not covered | May 26, 2026 | payer document |
| Aetna | Spinal Cord Stimulation (0194) | covered if criteria are met | Sep 10, 2026 | payer document |
| Aetna | Tinnitus Treatments (0406) | not covered | Jul 10, 2026 | payer document |
| Aetna | Tourette's Syndrome (0480) Ecopipam, pramipexole, VMAT-2 inhibitors (e.g., valbenazine), amphetamines, Deutetrabenazine (Austedo) | not covered | Jul 24, 2026 | payer document |
| Aetna | Trigeminal Neuralgia: Treatments (0374) Topical ambroxol, Erenumab, Intravenous ketamine | not covered | Jun 29, 2026 | payer document |
| Aetna | Urinary Incontinence (0223) | covered if criteria are met | Jul 16, 2026 | payer document |
| Aetna | Vagus Nerve Stimulation (0191) | covered if criteria are met | Mar 31, 2026 | payer document |
| Aetna | Vocal Cord Paralysis / Insufficiency Treatments (0253) HCPCS not covered for indications listed in the CPB [posterior cricoarytenoideus re-innervation and pacing] | not covered | Apr 15, 2026 | payer document |
| Anthem | Deep Brain Stimulation and Responsive Neurostimulation (SURG.00026) | covered if criteria are met | Aug 13, 2026 | payer document |
| Anthem | Gastric Electrical Stimulation (CG-SURG-70) | covered if criteria are met | Nov 6, 2025 | payer document |
| Anthem | Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain (SURG.00158) | covered if criteria are met | Nov 6, 2025 | payer document |
| Anthem | Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain (SURG.00158) | unproven / investigational | Nov 6, 2025 | payer document |
| Anthem | Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures) (SURG.00112) | unproven / investigational | Nov 6, 2025 | payer document |
| Anthem | Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence (CG-SURG-95) | covered if criteria are met | Aug 13, 2026 | payer document |
| Anthem | Vagus Nerve Stimulation (CG-SURG-120) | covered if criteria are met | Feb 19, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Implantable Peripheral Nerve Stimulation For Chronic Pain Conditions | unproven / investigational | payer document | |
| Blue Shield of California | Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions (1.01.31) | listed, no stance | payer document | |
| Blue Shield of California | Spinal Cord and Dorsal Root Ganglion Stimulation (7.01.25) | listed, no stance | payer document | |
| Blue Shield of California | Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (7.01.101) | listed, no stance | payer document | |
| Blue Shield of California | | Vagus Nerve Stimulation (7.01.20) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Occipital Nerve Stimulation (CAM 701125) 64999 | Unlisted procedure, nervous system | listed, no stance | May 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Spinal Cord and Dorsal Root Ganglion Stimulation (CAM 70125) | listed, no stance | Jan 1, 2026 | payer document |
| Capital Blue Cross | Deep Brain Stimulation (MP 1.042) | covered if criteria are met | Jun 1, 2026 | payer document |
| Capital Blue Cross | Gastric Electrical Stimulation (MP 2.069) Procedure codes | unproven / investigational | Jun 1, 2026 | payer document |
| Capital Blue Cross | Sacral Nerve Neuromodulation-Stimulation (MP 1.033) Procedure codes | covered if criteria are met | May 1, 2026 | payer document |
| Capital Blue Cross | Surgical Treatment of Sleep Apnea and Snoring (MP 1.128) Procedure codes | covered if criteria are met | Apr 1, 2026 | payer document |
| Centene | Fecal Incontinence Treatments (CP.MP.137) | covered if criteria are met | May 1, 2026 | payer document |
| Centene | Fecal Incontinence Treatments (CP.MP.137) Date | Date | not covered | May 1, 2026 | payer document |
| Centene | Gastric Electrical Stimulation (CP.MP.40) | covered if criteria are met | Jan 1, 2026 | payer document |
| Centene | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) | covered if criteria are met | Jan 1, 2026 | payer document |
| Centene | Vagus Nerve Stimulation (CP.MP.12) | covered if criteria are met | Jul 1, 2026 | payer document |
| Cigna | Deep Brain, Motor Cortex and Responsive Cortical Stimulation (0184) | covered if criteria are met | Nov 15, 2025 | payer document |
| Cigna | Deep Brain, Motor Cortex and Responsive Cortical Stimulation (0184) | unproven / investigational | Nov 15, 2025 | payer document |
| Cigna | Diaphragmatic/Phrenic Nerve Stimulation (0391) | covered if criteria are met | Jul 15, 2026 | payer document |
| Cigna | Gastric Pacing/Gastric Electrical Stimulation (GES) (0103) | covered if criteria are met | Nov 15, 2025 | payer document |
| Cigna | Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation (0539) | unproven / investigational | Mar 15, 2026 | payer document |
| Cigna | Sacral Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation (0404) | covered if criteria are met | Nov 15, 2025 | payer document |
| Cigna | Surgical Treatments for Obstructive Sleep Apnea (0158) | listed, no stance | Jun 15, 2026 | payer document |
| Cigna | Vagus Nerve Stimulation (VNS) (0350) | covered if criteria are met | Feb 15, 2026 | payer document |
| Cigna | Vagus Nerve Stimulation (VNS) (0350) | not covered | Feb 15, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Medical Policies Moving to MCG Guidelines Electrical Stimulation (GES) | 64590, 64595, 95980, 95981, | (Electrical) ACG: A-0395 | listed, no stance | Jan 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy (SUR712.039) CPT Codes 61850, 61860, 61863, 61864, 61880, 61885, 61886, 61888, 61889, | listed, no stance | Dec 1, 2025 | payer document |
| Premera Blue Cross | Deep Brain Stimulation (7.01.609) | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Gastric Electrical Stimulation (7.01.522) | listed, no stance | Apr 13, 2026 | payer document |
| Premera Blue Cross | Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain and Other Conditions (7.01.574) | listed, no stance | Jul 1, 2026 | payer document |
| Premera Blue Cross | Occipital Nerve Stimulation (7.01.125) | listed, no stance | Jun 8, 2026 | payer document |
| Premera Blue Cross | Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy (7.01.143) | listed, no stance | Oct 14, 2026 | payer document |
| Premera Blue Cross | Sacral Nerve Neuromodulation/Stimulation (7.01.69) | listed, no stance | Jun 8, 2026 | payer document |
| Premera Blue Cross | Spinal Cord and Dorsal Root Ganglion Stimulation (7.01.546) | listed, no stance | Jul 1, 2026 | payer document |
| Premera Blue Cross | Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (7.01.554) | listed, no stance | Jul 27, 2026 | payer document |
| Premera Blue Cross | Vagus Nerve Stimulation (7.01.593) | listed, no stance | Mar 23, 2026 | payer document |
Prior authorization required or conditional in IN, WA, WV.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.