Outpatient Behavioral Health Request — Transcranial Magnetic Stimulation Precertification Information Request
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This document is Aetna's outpatient behavioral health precertification information request form for Transcranial Magnetic Stimulation (TMS), describing required provider submissions and how Aetna will review requests for applicable commercial, Medicare Advantage, and certain delegated plans.
No material clinical or coverage changes in this revision.
Coverage and Clinical Review Criteria
Documentation and clinical criteria for review
Requests are reviewed using applicable CMS NCDs/LCDs for Medicare members and Clinical Policy Bulletin #469 for other members; coverage depends on documented clinical criteria.
Sections 1-6 completion required
The form asks the provider to identify any active conditions that could contraindicate Transcranial Magnetic Stimulation (TMS). Specific items listed for selection include: high alcohol or illicit drug consumption; metal implant in or around the head; other implants (e.g., pacemaker); neurological condition; psychosis; acute suicidal risk; catatonia; life‑threatening inanition; cardiovascular disease; and member currently receiving ECT. The form also requests, when relevant, the name and specialty of the clinician who cleared the member for TMS for cardiovascular disease or seizure disorder/epilepsy.
Coverage determinations for requests submitted on this form follow published Medicare guidance for Medicare Advantage members: Aetna uses applicable CMS benefit policies, including national coverage determinations (NCDs) and local coverage determinations (LCDs), when available. For non‑Medicare members, the form references Clinical Policy Bulletin #469 (Transcranial Magnetic Stimulation and Cranial Electrical Stimulation) as the Aetna resource to guide coverage decisions. The form itself cannot be used to initiate a precertification request for commercial plans and must be submitted according to the plan’s precertification procedures.
Procedure Codes
Submission, Documentation, and Prior Authorization
Submission and prior authorization routing
Submit precertification requests electronically via Availity (preferred) or send by confidential fax to the plan-specific Precertification numbers listed on the form. The form itself cannot be used to initiate a precertification request for commercial plans; use the member's card number to call the commercial precertification phone number instead.
- Preferred electronic submission: Provider Portal at www.Availity.com.
- Fax numbers: Aetna Leap Plans 888-934-7941 (TTY: 711); Medicare Plans 959-282-8799 (TTY: 711); Commercial Plans 888-463-1309 (TTY: 711).
- For commercial plans that do not accept this form to initiate precertification, call the number on the member's ID card.
Prior therapy requirements
Document prior therapies during the current depressive episode, including evidence-based psychotherapy and multiple psychopharmacologic trials (including augmenting agents); these are required as part of the review.
- Document evidence-based psychotherapy: type, provider, dates (start/finish), frequency, effectiveness, and supporting rating scale scores with dates.
- Document all psychopharmacologic trials (including augmentative agents): list dates, doses, outcomes, and specific side effects that led to discontinuation.
Required clinical documentation
Include detailed clinical documentation: presenting problems and symptoms, date of most recent onset, depression rating scales (name, date, score), and full prior TMS history with dates, number of sessions, and treatment response.
- Presenting problems and symptoms and date of most recent onset of acute symptoms.
- Depression rating scales that support diagnosis (e.g., BDI, HDRS, MADRS) with name, date, and score.
- If prior TMS: include note dates, number of sessions, and response including rating scale results and dates.
Incomplete submission may cause denial
Failure to complete this form and submit all requested medical records may result in delay of review or denial of coverage.
- As the attending physician, you must complete Sections 1 through 6 of the form.
- Incomplete submission or missing requested records can delay review or lead to denial.
Transcranial Magnetic Stimulation (TMS)
TMS
Referenced Policies and Definitions
Background and Purpose
Background: This outpatient precertification form supports clinical review of TMS for patients with major depressive disorder. For Aetna Medicare Advantage members, coverage decisions are made using CMS benefit policies, including NCDs and LCDs, and when no applicable Medicare determination exists, Aetna references its Clinical Policy Bulletin #469 for non‑Medicare members. The form guides collection of clinical information needed for review — including presenting problems, onset date, objective depression rating scales, prior TMS history, psychotherapy during the current episode, detailed psychopharmacologic trials (dates, doses, outcomes, side effects and augmentation trials) — and warns that failure to complete the form and submit all requested medical records may result in delay or denial of coverage.
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