ModifiedAmbetter GeorgiaPolicy CP.BH.201

Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive-Compulsive Disorder

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Medical necessity criteria and coverage stance for deep transcranial magnetic stimulation (dTMS) to treat adults with obsessive-compulsive disorder (OCD) for members of Ambetter Georgia (Centene-affiliated plans).

Policy Summary

PayerAmbetter Georgia

PolicyDeep Transcranial Magnetic Stimulation for the Treatment of Obsessive-Compulsive Disorder

Policy CodePolicy CP.BH.201

Change TypeCoverage criteria and thresholds reviseddevice and session limits updated

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of age ≥18, DSM-confirmed OCD, prior adequate trials of CBT/ERP and medications, baseline and follow-up Y-BOCS scores, and planned use of an FDA-cleared dTMS device.

SourceLink

POLICY UPDATE CHANGES

Initial recommended acute treatment sessions changed from 20 to 30 sessions (and at times updated to request up to 36 sessions with optional tapering sessions).

Requirement that dTMS be administered using an FDA-cleared device and in accordance with labeled indications; lists of FDA-approved devices were added.

Response and continuation thresholds for Y-BOCS score reduction were changed (25% → 30% in some continuation/maintenance criteria; other response thresholds adjusted).

Contraindications and relative contraindications list was edited across revisions (items removed and added, including changes for neurologic disease, pregnancy, and active suicidal ideation wording).

Statements about medical director review and reviewer roles were added, moved, and in some revisions removed (language changed about requiring medical director review).

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ModifiedAmbetter GeorgiaPolicy CP.BH.201

Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive-Compulsive Disorder

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Policy Summary

PayerAmbetter Georgia

PolicyDeep Transcranial Magnetic Stimulation for the Treatment of Obsessive-Compulsive Disorder

Policy CodePolicy CP.BH.201

Change TypeCoverage criteria and thresholds reviseddevice and session limits updated

Effective DateJun 1, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Initial recommended acute treatment sessions changed from 20 to 30 sessions (and at times updated to request up to 36 sessions with optional tapering sessions).

Requirement that dTMS be administered using an FDA-cleared device and in accordance with labeled indications; lists of FDA-approved devices were added.

Response and continuation thresholds for Y-BOCS score reduction were changed (25% → 30% in some continuation/maintenance criteria; other response thresholds adjusted).

Contraindications and relative contraindications list was edited across revisions (items removed and added, including changes for neurologic disease, pregnancy, and active suicidal ideation wording).

Statements about medical director review and reviewer roles were added, moved, and in some revisions removed (language changed about requiring medical director review).

≥18minimum age for coverage

30 (up to 36)recommended initial dTMS sessions

<25%Y-BOCS improvement threshold cited

4psychopharmacologic trials required

≥24severe OCD threshold (Y-BOCS)

Multiplerevision history entries

Coverage Criteria for dTMS in OCD

Initial Treatment — Covered when ALL of the following are met

Covered when ALL of the following are met

Initial dTMS coverage criteria: A. Member/enrollee is ≥ 18 years old; B. Confirmed DSM diagnosis of obsessive‑compulsive disorder (OCD); C. OCD is not part of a presentation with multiple psychiatric comorbidities; D. Failed to respond to a combination of multiple medication trials plus Cognitive Behavioral Therapy (CBT) and/or Exposure and Response Prevention (ERP) for at least 12 weeks during the current episode as demonstrated by failure-to-respond pathways (see failure definition node); E. Member/enrollee is referred for TMS treatment by the provider treating the OCD symptoms; F. Planned use of the Yale‑Brown Obsessive‑Compulsive Scale (Y‑BOCS) with documented baseline score prior to treatment and monitoring throughout treatment; G. Request is for up to 36 sessions (recommended schedule ~5 days/week for ~6 weeks with optional taper sessions); H. Treatment is administered using an FDA‑cleared device and in accordance with labeled indications (examples listed in policy); I. Direct supervision of treatment by a licensed psychiatrist except where state scope allows other providers; J. No listed contraindications (see contraindication list for implants, other stimulators, pacemaker/defibrillator, intracardiac lines, medication pumps, <3 months remission from SUD, known non-adherence, or excluded comorbid mental health disorders).

See the separate failure-to-respond criteria for details on D; device examples and contraindications are listed in policy.

Failure to respond — detailed

Within criteria D above, failure to respond is defined as:

Failure to respond definition: 1) Less than 25% improvement in the Yale‑Brown Obsessive‑Compulsive Scale (Y‑BOCS) during the current episode; OR 2) Failure to respond to psychopharmacologic agents defined as lack of clinically significant response in the current episode after four trials of agents representing at least two different classes, with one of the following: a) At least two trials were adequate SSRI/SNRI/clomipramine or atypical antipsychotic augmentation at standard therapeutic doses for ≥12 weeks; OR b) The member/enrollee is unable to take SSRI, SNRI, clomipramine, or atypical antipsychotics because of drug interactions or intolerance, evidenced by trials of four agents with distinct side‑effect profiles in the current episode.4 medication trials; ≥12 weeks for adequate SSRI/SNRI/clomipramine/augmentation trials

Policy lists multiple pathways to establish failure to respond (symptom-based or treatment-trial based).

Coverage criteria and response thresholds (summary)

Covered when ALL of the following are met (policy details and response thresholds summarized below):

Maintenance not covered: Maintenance deep TMS (dTMS) for OCD is considered not medically necessary; requests for maintenance courses are not supported by the available peer‑reviewed literature and may be denied.

Policy explicitly states maintenance dTMS is not medically necessary.

Retreatment — case‑by‑case review: Retreatment requests will be reviewed and are discretionary; medical director (or designated clinical reviewer) review is informed by: A. Continued meeting of initial treatment criteria; B. Current symptom worsening with Y‑BOCS > 15; C. Documentation that prior response achieved at least a 30% reduction from baseline with durability of approximately 6 months.Y‑BOCS > 15; prior response ≥ 30% with ~6 months durability

Retreatment requires case‑by‑case review using these elements.

This policy identifies specific contraindications and device requirements for deep transcranial magnetic stimulation (dTMS) for obsessive‑compulsive disorder. dTMS must be administered with an FDA‑cleared device consistent with labeled indications and in a clinical setting with direct supervision by a licensed psychiatrist except where state scope of practice allows otherwise. Members with conductive, ferromagnetic, or other magnetic‑sensitive metal implants in the head or neck within 30 cm of coil placement (examples include cochlear implants, implanted electrodes/stimulators, aneurysm clips/coils, stents, bullet fragments, metallic tattoo dyes, and certain vagus nerve stimulator leads) or with other implanted stimulators (for example, deep brain stimulators) are contraindicated for dTMS and may be denied coverage. The policy’s contraindication list has been revised across updates; reviewers should follow the current listed items in this policy when assessing eligibility.

dTMS is covered only for adults. The policy requires the member be ≥ 18 years old and documents that procedures are currently approved for adults only; pediatric use is not supported in this document. Providers must document a DSM diagnosis of OCD and provide baseline and ongoing severity measurement using the Yale‑Brown Obsessive‑Compulsive Scale (Y‑BOCS) when requesting authorization.

Maintenance dTMS for OCD is considered not medically necessary due to insufficient peer‑reviewed evidence and, as such, requests for maintenance courses may be denied. The policy explicitly states maintenance treatment is not supported and should not be authorized outside of the defined acute/initial treatment criteria.

Requests that do not meet the policy’s numeric session limits, device requirements, or required documentation may be considered not medically necessary. The acute treatment course is typically documented as approximately 30 sessions in recent revisions, with the policy allowing requests for up to 36 sessions (recommended schedule five days per week for six weeks with an optional six‑session taper) when supported by documentation. Prior authorization must include documented baseline and follow‑up Y‑BOCS scores, evidence of prior adequate trials (medication and CBT/ERP), and use of an FDA‑cleared device. Failure to provide required documentation or to remain within the stated device, session, and response thresholds can result in denial.

Treatment Modalities and Device Requirements

inv-28: dTMS/TMS — 1 top-level node

dTMS/TMS modality requirements: Use FDA-cleared devices administered per device labeling; examples in policy include Brainsway H7 coil, MagVenture cool DB80 coil, Magstim Horizon 3.0 with E-z Cool Coil, NeuroStar Advanced Therapy System, and Apollo TMS Therapy System. Treatment should be supervised by appropriate licensed personnel per state scope of practice.Adults only per current approvals

Device examples and FDA approvals cited in policy.

inv-29: Deep Transcranial Magnetic Stimulation (dTMS) — 1 top-level node

Deep Transcranial Magnetic Stimulation (dTMS) device and patient criteria: Treatment must be administered using an FDA-cleared device and in accordance with labeled indications; planned use of Y-BOCS to measure baseline severity and response; procedures are currently approved for adults only.Adults only per current approvals

Session Limits and Visit Frequency

dTMS — Session limits

Maximum sessions (initial)Up to 36 sessions for the initial course (recommended schedule five days/week for six weeks with optional six-session taper)

Typical acute course (recommended)Approximately 30 sessions (documented in revisions as typical; some revisions changed initial request from 20 to 30)

Session frequencyFive days per week for six weeks (per recommended schedule)

dTMS treatment sessions — typical and revised limits

Standard acute course (typical)30 sessions (documented as the changed initial request in revision history)

Permitted maximum (per revisions)Up to 36 sessions including optional six-session taper (requests for up to 36 sessions should be supported)

Billing and Coding

Covered CPT Codes (referenced)CPT

90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery, and management.
90868	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session.
90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management.
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended).
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.

Added CPT/HCPCS codes (revision notes)CPT | HCPCS

97014	Application of a modality to 1 or more areas; electrical stimulation (unattended)
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Y-BOCS response thresholds

Primary response definition (policy criteria)Less than 25% improvement in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is defined as failure to respond in one pathway.

Alternate response thresholds referencedDocument also references reductions of 25% or 35% and revision notes indicate later use of ~30% reduction for some continuation/retreatment decisions.

Retreatment durability thresholdPrior treatment response of at least a 30% drop from baseline with documented 6-month duration is cited for retreatment review.

Y-BOCS severity thresholds (score bands)

Severe OCD thresholdY-BOCS score: Severe 24–31 (score ≥24 indicates severe OCD)

Moderate

Provider Requirements, Prior Auth, and Documentation

Prior Authorization

Prior authorization required — adult DSM-confirmed OCD and prior trials documented

Submit prior authorization demonstrating that all coverage criteria are met, including member age ≥ 18, a DSM-confirmed diagnosis of OCD, documentation that the member failed to respond to adequate trials of medications plus CBT/ERP for at least 12 weeks in the current episode, and provision of baseline Y-BOCS score; support requests for up to 36 sessions with documentation of the planned schedule.

Age ≥ 18 required (I.A).
DSM-confirmed diagnosis of OCD required (I.B).
Failure to respond to medication + CBT/ERP for ≥12 weeks must be documented (I.D).
Provide baseline Y-BOCS and indicate request is for up to 36 sessions (I.F; I.G).

Step Therapy

Step therapy — document failure of first-line medications and CBT/ERP

Document prior treatment failures showing the member did not respond to first-line therapies before authorizing dTMS: at minimum SSRIs/SNRIs or clomipramine (with adequate 12-week trials where applicable) and a course of CBT/ERP must be attempted and recorded.

Definitions and Measurement Scales

Deep Transcranial Magnetic Stimulation (dTMS) — H‑7 coil and targets

Modality descriptionDeep Transcranial Magnetic Stimulation (dTMS) uses an H‑7 coil to stimulate deeper brain structures implicated in OCD, including the anterior cingulate cortex (ACC) and medial prefrontal cortex (mPFC)

H‑7 coilDesigned to reach deeper targets beyond surface TMS (dTMS coil design allows stimulation of deeper brain structures)

Indication contextdTMS (H7 coil) received FDA clearance (August 2018) as an adjunctive treatment for adults with OCD

Yale‑Brown Obsessive Compulsive Scale (Y‑BOCS) — overview

Scale length and scoringY‑BOCS is a 10‑item scale with each item scored 0–4; total score range 0–40

What it measuresRates severity and type of obsessive and compulsive symptoms across time occupied, interference, distress, resistance, and control

Background

Obsessive‑compulsive disorder (OCD) is a chronic disorder characterized by intrusive obsessions and repetitive compulsions that can be severe and persistent. Deep transcranial magnetic stimulation (dTMS) is a noninvasive neuromodulation technique that uses specialized coils (for example the H‑7 coil) to stimulate deeper cortical and subcortical targets implicated in OCD, and it has received FDA clearance for adjunctive treatment of adults with OCD. dTMS is positioned in this policy as an option for adults with moderate‑to‑severe, treatment‑resistant OCD who meet the policy’s step‑therapy and documentation requirements (adequate trials of CBT/ERP and pharmacotherapy and documented baseline and follow‑up Y‑BOCS scores).

Policy Revision History

12/22revision

Initial recommended acute dTMS sessions changed from 20 to 30 sessions in the policy text.

03/24revision

Policy updated to note requests may be for up to 36 sessions; recommended schedule five days/week for six weeks with an optional six‑session taper described.

02/25revisionLatest

Policy Summary

PayerAmbetter Georgia

PolicyDeep Transcranial Magnetic Stimulation for the Treatment of Obsessive-Compulsive Disorder

Policy CodePolicy CP.BH.201

Change TypeCoverage criteria and thresholds reviseddevice and session limits updated

Effective DateJun 1, 2026

Next Review DateN/A

SourceLink

On This Page

Policy notes dTMS with H7 coil was cleared for adjunctive treatment of adults with OCD; device examples listed in criteria.

Recommended scheduleFive days per week for six weeks with optional tapering sessions

Y-BOCS score: Moderate 16–23

Mild and other bandsSubclinical <8; Mild 8–15; Extreme 32–40

At least two adequate SSRI/SNRI/clomipramine trials (12 weeks) among four total medication trials pathway (I.D; 4.a).
Documented trial of Cognitive Behavioral Therapy (CBT) and/or Exposure and Response Prevention (ERP) (I.D).

Billing Rule

Prior authorization and coding notes — prior auth required; note added CPT/HCPCS codes

Obtain prior authorization for acute dTMS consistent with the policy and bill using the referenced CPT codes; note revision additions of CPT/HCPCS codes 97014 and 97032 in the policy history.

Prior authorization required for acute dTMS requests per policy (prior auth references include 90867/90868/90869 for TMS procedures).
Policy revision notes list added codes 97014 and 97032 (03/24 revision).

Documentation Required

Required clinical documentation — baseline and monitored Y-BOCS; prior trials

Include documented baseline Y-BOCS score and ongoing monitored Y-BOCS scores during the course of treatment, plus detailed records of prior medication and CBT/ERP trials including duration and adequacy.

Baseline Y-BOCS score must be recorded prior to treatment and monitored throughout (I.F; Y-BOCS description).
Document prior pharmacologic and CBT/ERP trials with durations and adequacy (I.D; documentation requirements).

Documentation Required

Referral documented by treating provider

Document the referring clinician: include evidence that the provider treating the member's OCD symptoms referred the member for TMS treatment.

Referral from the provider treating the OCD symptoms must be included with the request (I.E).

Documentation Required

Include baseline & follow-up Y-BOCS and evidence of FDA-cleared device use

Provide both baseline and follow-up Y-BOCS scores and documentation that treatment will be (or was) delivered using an FDA-cleared dTMS device listed in the policy.

Planned use and documentation of Y-BOCS prior to and during treatment required (I.F).
Treatment must be administered using an FDA-cleared device (examples listed in I.H).

Denial Risk

Contraindications — metallic/ferromagnetic implants and implanted stimulators

Do not treat or request authorization for members with contraindicated implants or devices; presence of conductive/ferromagnetic implants in the head/neck within 30 cm of coil placement, implanted stimulators (e.g., deep brain stimulators), or cardiac pacemakers/ICDs may preclude coverage.

Contraindications include conductive or ferromagnetic metals implanted/embedded in head or neck within 30 cm of coil (I.J.1).
Other implanted stimulators such as deep brain stimulation and cardiac pacemakers/defibrillators are contraindications (I.J.2; I.J.1.a).

Denial Risk

Maintenance dTMS not covered — maintenance requests may be denied

Do not request authorization for maintenance dTMS; maintenance treatment for OCD is considered not medically necessary and such requests may be denied.

Policy explicitly states maintenance dTMS for OCD is not medically necessary (maintenance stance).

Denial Risk

Requests exceeding allowed sessions or missing documentation may be denied

Ensure requests do not exceed the allowed session limits and that required documentation is complete; requests exceeding the documented session limits or lacking baseline/follow-up severity measures or device documentation may be denied.

Policy allows initial acute course requests for up to 36 sessions (revision notes).
Incomplete documentation of Y-BOCS scores or device use risks denial.

Note

Provider actions — submit complete authorization package and confirm supervision

For high‑importance administrative compliance: include all documentation elements above, confirm direct supervision arrangements per state scope, and supply any additional requested records promptly to avoid denial or delay.

Direct supervision by a licensed psychiatrist required except where state scope allows otherwise (I.I).
Provide full prior authorization package (diagnosis, prior trials, Y-BOCS baseline and monitoring, device information, session count).

Use in policyPlanned use of the Y‑BOCS is required to document baseline and monitor response during dTMS treatment

Y‑BOCS — items, scoring, and interpretation

Item scoringEach of the 10 items is scored 0–4 (0 = no symptoms to 4 = extreme symptoms)

Total score interpretationTotal score ranges 0–40 with bands: Subclinical <8; Mild 8–15; Moderate 16–23; Severe 24–31; Extreme 32–40

Clinical applicationUsed to document baseline severity and to assess treatment response (percent reduction thresholds referenced in policy)

Policy language revised to set request allowance to up to 36 approved sessions and to describe the optional six‑session taper; frequency/language about session counts adjusted across sections.

12/22revision

Policy was restructured and the initial session count in the initial request was changed from 20 to 30 sessions and FDA‑cleared device language was added.

03/24revision

Continuation and taper language updated: 'request for taper of six final sessions' replaced prior wording for additional sessions and device/examples list added; coding and background updated.

02/25revisionLatest

Frequency and total session language edited to indicate requests for up to 36 sessions and to describe recommended schedule and optional tapering sessions.

03/24revision

Response thresholds were changed in multiple continuation criteria from a 25% reduction to a 30% reduction in Y‑BOCS; 'No active suicidal ideation with intent' was added to contraindications and CPT/HCPCS codes 97014 and 97032 were added.

03/24revision

Contraindication list was edited to remove neurologic disease/brain injury and pregnancy and to add items such as 'No active suicidal ideation with intent' in that revision.

02/25revisionLatest

Policy removed the requirement that requests must be reviewed by a medical director and adjusted medical director/reviewer language across sections.