CurrentAmbetter NevadaPolicy CP.BH.201

Deep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder (PDF)

Defines medical necessity criteria, contraindications, limits, and coding guidance for deep transcranial magnetic stimulation (dTMS) to treat OCD for health plans affiliated with Centene Corporation (Ambetter Nevada). Includes initial treatment, maintenance (not medically necessary), and retreatment review criteria.

Policy Summary

PayerAmbetter Nevada

PolicyDeep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder (PDF)

Policy CodePolicy CP.BH.201

Change TypeRevisions to criteria, limits, contraindications

Effective Date

Next Review Date

Key ActionDocument baseline Y-BOCS prior to treatment and monitor scores throughout the course; request up to 36 sessions with recommended five days/week for six weeks (optional six-session taper) and provide prior treatment documentation.

SourceLink

POLICY UPDATE CHANGES

Request limit changed from 30 to 36 approved sessions; recommended schedule five days/week x 6 weeks with optional six-session tapering noted.

Initial treatment criteria clarified to require member/enrollee ≥18, DSM diagnosis, absence of multiple psychiatric comorbidities, and documented failed trials of therapy and medications.

Maintenance dTMS stated as not medically necessary.

Retreatment criteria defined to require prior ≥30% response with documented 6-month duration and Y-BOCS worsening >15.

Updated list of FDA-cleared devices acceptable for use (Brainsway H7 coil, MagVenture cool DB80 coil, Magstim Horizon 3.0 + E-z Cool Coil, NeuroStar Advanced Therapy System, Apollo TMS Therapy System).

Contraindication list standardized to implants/metal within 30 cm, implanted stimulators, less than 3 months remission from substance use disorder, non-adherence, and other mental health disorders; removed several previous relative contraindications (e.g., history of seizures, severe dementia, severe cardiovascular disease, active suicidal ideation with intent).

36Maximum sessions authorized per request

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4Required pharmacologic trials prior to approval

Not coveredMaintenance dTMS stance

Coverage Summary

This policy defines medical necessity criteria for initial deep transcranial magnetic stimulation (dTMS) using an H7 coil for adults with obsessive-compulsive disorder (OCD). It covers initial dTMS when all specified criteria are met (age ≥18, DSM diagnosis of OCD, limited psychiatric comorbidity, documented failed trials of CBT/ERP and pharmacotherapy, documented baseline and ongoing Y-BOCS monitoring, use of an FDA‑cleared device, direct supervision, and up to 36 sessions on a recommended schedule of five days/week for six weeks with an optional six‑session taper). Maintenance dTMS is explicitly stated as not medically necessary and is not covered. Retreatment is considered case-by-case with defined thresholds for prior response and current worsening.

Age>= 18 years

Prior CBT/Medication Duration>= 12 weeks during current episode

Pharmacologic trialsFour trials representing >=2 different agent classes (with at least two adequate SSRI/SNRI/clomipramine/atypical antipsychotic trials of >=12 weeks)

Y-BOCS failure threshold< 25% improvement

Retreatment prior response>= 30% drop from baseline with documented 6-month duration of response

Y-BOCS retreatment worsening> 15

Maximum sessions per requestUp to 36 sessions (recommended schedule: 5 days/week x 6 weeks with optional 6-session taper)

Medical Necessity Criteria

Initial dTMS Treatment - Medically Necessary

Covered when ALL of the following are met:

ALL of the following

Member/enrollee is ≥ 18 years old>= 18 years
Confirmed diagnosis of obsessive-compulsive disorder (OCD) per the current Diagnostic and Statistical Manual of Mental Disorders (DSM)
OCD is not part of a presentation with multiple psychiatric comorbidities
Failed prior treatments
- Pharmacologic failure definition

Coding

Referenced CPT codes for TMSCPT

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

Provider Actions

Prior Authorization

Session limit and request

Requests should be for up to 36 sessions; recommended schedule five days/week for six weeks with optional six-session taper.

90867
90868
90869

Documentation Required

Document Y-BOCS scores

Document baseline Y-BOCS prior to treatment and monitor scores throughout course of treatment.

Documentation Required

Prior treatment documentation

Background & Evidence

Deep TMS with the H7 coil received FDA clearance in August 2018 as an adjunctive treatment for adults with OCD. TMS (including rTMS and dTMS) is presented as a non‑invasive option for treatment‑resistant OCD that can target frontal brain networks implicated in OCD (e.g., ACC and mPFC). First‑line treatments remain CBT with Exposure and Response Prevention (ERP) and pharmacotherapy (typically SSRIs) often combined with psychotherapy. Evidence cited includes randomized controlled trials and meta‑analyses showing moderate effect sizes and higher response rates for active dTMS versus sham (for example, Carmi et al. 2019 RCT: active response 38.1% vs sham 11.1% post‑treatment and 45.2% vs 17.8% at 1‑month; Steuber & McGuire 2023 meta‑analysis: g=0.65, response ~39.5% vs 8.8%; Roth et al. 2021 real‑world data showing first and sustained response rates of 72.6% and 52.4%).

Evidence	Finding
Carmi et al. 2019 RCT	Active dTMS response rates 38.1% vs sham 11.1% post-treatment; 45.2% vs 17.8% at 1-month follow-up
Roth et al. 2021 real-world	First and sustained response rates 72.6% and 52.4%; mean first response after ~18.5 sessions; continued improvement with additional sessions
Meta-analysis (Steuber & McGuire 2023)	Moderate effect size g=0.65; average response rTMS 39.5% vs sham 8.8%

Y‑BOCS: the Yale‑Brown Obsessive Compulsive Scale is a 10‑item clinician‑rated measure with total scores ranging from 0–40. Severity translation: Subclinical <8; Mild 8–15; Moderate 16–23; Severe 24–31; Extreme 32–40. The scale is required for baseline documentation and ongoing monitoring in the treatment course.

Medicare Determinations

Name	Number	Effective Date	Type
Transcranial Magnetic Stimulation (TMS)	L33398	2015-10-01	LCD

Revision History

revisedLatest

Request limit changed from 30 to 36 approved sessions; recommended schedule five days/week x 6 weeks with optional six-session tapering noted.

revisedLatest

Initial treatment criteria clarified to require member/enrollee ≥18, DSM diagnosis, absence of multiple psychiatric comorbidities, and documented failed trials of therapy and medications.

Policy Summary

PayerAmbetter Nevada

PolicyDeep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder (PDF)

Policy CodePolicy CP.BH.201

Change TypeRevisions to criteria, limits, contraindications

Effective Date

Next Review Date

SourceLink

On This Page

Lack of clinically significant response in the current OCD episode to four trials of agents representing at least two different agent classes4 trials; >=2 classes

And one of the following

At least two of the treatment trials were administered as an adequate course of mono- or poly-drug therapy with SSRIs, SNRIs, clomipramine, or atypical antipsychotic augmentation involving standard therapeutic doses of at least 12 weeks duration>= 12 weeks for at least 2 trials
Member/enrollee is unable to take SSRI, SNRI, clomipramine, or atypical antipsychotics due to (i) drug interactions with medically necessary medications, or (ii) inability to tolerate psychopharmacologic agents as evidenced by trials of four such agents with distinct side effects in the current episode4 distinct trials if intolerance
Less than 25% improvement in the Yale Brown Obsessive Compulsive Scale (Y-BOCS)< 25% improvement

Member/enrollee is referred for TMS treatment by the provider treating the OCD symptoms

Planned use of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), documenting the score prior to treatment, and monitored throughout course of treatmentDocument baseline and ongoing Y-BOCS

Request is for up to 36 sessionsUp to 36 sessions

Recommended schedule: five days a week for six weeks, with an optional six sessions for tapering

TMS treatment is administered using an FDA-cleared device and utilized in accordance with FDA labeled indications (examples listed)FDA-cleared device

Examples: Brainsway H7 coil; MagVenture cool DB80 coil; Magstim Horizon 3.0 + E-z Cool Coil; NeuroStar Advanced Therapy System; Apollo TMS Therapy System

Direct supervision of treatment is provided by a licensed psychiatrist except where state scope of practice allows other provider types to supervise

No contraindications (NONE of the following present)

Conductive or ferromagnetic or other magnetic-sensitive metals implanted or embedded in head or neck within 30 cm of dTMS H7 coil placement (other than dental fillings)within 30 cm
Includes cochlear implants; implanted electrodes/stimulators; aneurysm clips or coils; stents; bullet fragments; metallic dyes in tattoos; vagus nerve stimulator leads in the carotid sheath
Other implanted stimulators controlled by or that use electrical or magnetic signals
Includes deep brain stimulation, cardiac pacemaker, cardioverter defibrillator, intracardiac lines, medication pumps
Less than three months of substantiated remission from a substance use disorder< 3 months remission
Known non-adherence with previous treatment for OCD
Any mental health disorder other than OCD (e.g., mood disorders, psychotic disorders, other anxiety disorders, etc.)

Maintenance dTMS Treatment

Maintenance treatment determination

Maintenance treatment with dTMS for OCD is considered NOT medically necessary due to insufficient peer-reviewed literature to support maintenance

Provide documentation of failed trials: multiple medication trials (four trials representing at least two classes) and CBT/ERP trials for ≥12 weeks during current episode.

Denial Risk

Contraindications

Claims may be denied if member has contraindicated implants/devices within 30 cm of coil, other implanted stimulators, <3 months remission from substance use disorder, known non-adherence, or other mental health disorders besides OCD.

Billing Rule

Use FDA-cleared device and follow labeled indications

dTMS must be administered using an FDA-cleared device in accordance with labeled indications (examples provided).

Documentation Required

Provider referral requirement

Member must be referred for TMS treatment by the provider treating the OCD symptoms.

Prior Authorization

Retreatment requires case-by-case review

Retreatment will be reviewed by medical director using specified criteria (initial criteria continued, Y-BOCS>15, prior ≥30% response with 6-month duration).

Maintenance dTMS stated as not medically necessary.

revisedLatest

Retreatment criteria defined to require prior ≥30% response with documented 6-month duration and Y-BOCS worsening >15.

revisedLatest