Transcranial Magnetic Stimulation (TMS) Precertification Information Request
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Aetna's outpatient behavioral health precertification information request form used to initiate clinical review for TMS for Aetna Medicare Advantage and certain managed plans; it specifies required documentation, submission methods, and clinical details providers must supply.
Effective January 31, 2025, this form replaces all other Transcranial Magnetic Stimulation precertification request documents and forms.
Coverage and Applicability
Clinical review and documentation criteria
Coverage decisions are determined after clinical review; Medicare Advantage determinations follow CMS NCDs/LCDs when available, otherwise Aetna's Clinical Policy Bulletin #469 is used.
Clinical review will determine coverage; missing documentation may delay or result in denial
This form is intended for use with Aetna Medicare Advantage plans and with certain health plans for which Aetna provides management services (for example, Innovation Health Plan, Inc. and Innovation Health Insurance Company). Do not use this form for Traditional Choice/Indemnity plans, other Commercial plans (including Commercial plans in Maryland or Massachusetts), for extension requests, or to initiate a precertification request for those Commercial plans; Commercial members should be precertified using the number on the member’s ID card.
If the completed form and all requested medical records are not provided, Aetna may delay review or deny coverage after clinical review. Providers should submit the full, completed form and the supporting documentation (see Sections 1–6 on the form) to avoid processing delays and potential denials.
Procedure Codes and Post-treatment
Submission, Required Documentation, and Denial Risk
Precertification Submission Requirement
Precertification is required. Complete and submit the TMS Precertification form and all requested medical records to Aetna’s Precertification Department before services begin. Preferred submission method is electronic upload via the secure provider portal at Availity.com. Confidential fax lines are available if needed: Commercial plans: 1-888-463-1309; Medicare plans: 1-959-282-8799. You may also call the Precertification Department to initiate a request.
- Preferred: electronic upload at Availity.com
- Commercial fax: 1-888-463-1309
- Medicare fax: 1-959-282-8799
Incomplete Submission May Lead to Denial
If you do not complete the form and submit all requested medical records, Aetna may delay review or deny coverage. Incomplete submissions can result in processing delays while we request missing information and can lead to denial if required documentation is not provided.
Required Clinical Documentation
Provide the completed form sections 1–6 and include: current behavioral health diagnosis code(s); validated rating scale name(s), dates and scores that support the diagnosis; planned start date and requested CPT/HCPCS codes and number of sessions; and any safety screening items (e.g., metal implants, seizure disorder, ECT, suicidality). For Medicare requests, document evidence-based psychotherapy details (type, provider, dates, frequency, effectiveness) and include rating scale scores pre/post therapy where applicable.
- Completed form Sections 1–6
- Current behavioral health ICD-10 diagnosis code(s)
- Validated rating scale name(s), dates, and scores
- Planned TMS start date and requested CPT/HCPCS codes with number of sessions
- Safety screening responses and explanations
- For Medicare: documentation of evidence-based psychotherapy trial(s) with dates, frequency, provider, and outcomes
Prior Therapy Documentation
Document all psychopharmacologic trials during the current episode, including augmenting agents. For each trial provide medication name (primary or augmenting and which agent it augments), dose, full start and stop dates, and outcome (response, intolerance, reason for discontinuation). For Medicare requests, psychotherapy trial documentation is required as noted above.
- Full dates, doses, and outcomes for every medication trial in the current episode
- Identify primary vs augmenting medication and the antidepressant being augmented
- Document side effects or dose-limiting issues and reason for stopping
Outpatient Criteria
Transcranial Magnetic Stimulation (TMS)
TMS
Section 3 requires exhaustive medication trial data
Background and Related Policies
This precertification information request form supports clinical review of Transcranial Magnetic Stimulation (TMS) treatment requests. Effective January 31, 2025, it replaces all prior TMS precertification request documents and forms. The form collects the clinical details reviewers need—diagnosis, episode dates, validated rating scales and scores, full psychopharmacologic trial records (dates, doses, outcomes), prior TMS history, and, for Medicare members, documentation of psychotherapy during the current episode—and it identifies the authorized submission methods for initiating review.
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