CurrentAnthem Blue Cross (California)Policy N/A

Transcranial Magnetic Stimulation Request Form

A payer-specific request/authorization form to collect clinical, device, treatment, prior therapy, and billing code information to support utilization management review for TMS (including rTMS and theta burst stimulation) for commercial members of Anthem Blue Cross California.

Policy Summary

PayerAnthem Blue Cross (California)

PolicyTranscranial Magnetic Stimulation Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review DateAug 1, 2025

Key ActionFax the completed form to 877-521-4780 or submit via Availity to initiate utilization management review, including required clinical fields, medication trials, rating scales, device information, and requested CPT codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes identified in this update.

2CPT codes listed

18+Minimum age indicated

30Standard max acute course

TMS Authorization Request Form — At-a-Glance

This form is an authorization request tool used by Anthem Blue Cross California to collect the clinical and administrative information necessary for utilization management review of Transcranial Magnetic Stimulation (TMS), including repetitive TMS (rTMS) and theta burst stimulation (TBS). It is designed to document member and provider details, diagnosis, prior treatment history, device safety concerns, treatment parameters (e.g., high-frequency or low-frequency rTMS and TBS), and requested billing codes/CPTs for the proposed course of therapy.

The form collects: member identifiers and contact information; requesting office and provider identifiers; confirmation of the requested modality (TMS of the brain and/or TBS) and treatment parameters; detailed prior medication trials and psychotherapy history; standardized depression rating scale scores with dates; implanted magnetic‑sensitive device or nearby metal information for device safety; intended treatment course and parameters (frequency, laterality, number of sessions, taper plans); and requested CPT codes with start dates and session/unit counts for billing and utilization review purposes.

Coverage stance: informational — the form is used to gather the clinical and administrative data required for UM review rather than to itself establish coverage policy.

TMS authorization form: scope and thresholds

Scope summaryPayer-specific authorization form to collect clinical, device, treatment, prior therapy, and billing code information to support utilization management review for TMS (including rTMS and theta burst stimulation) for Anthem Blue Cross California commercial members.

Standard treatment course frequency/durationUp to 5 days/week for 6 weeks (total of 30 sessions), followed by a taper.

Age thresholdPatients must be 18 years or older.

Treatment-resistance medication trials requirementInadequate response to pharmacotherapy despite trials with two or more antidepressant classes (adequate duration/dosage or documented adherence or inability to tolerate two trials with documented side effects).

Standard max acute course30 sessions (standard acute/index course: ≤5 days/week for 6 weeks, total 30 sessions).

Information requested to support TMS authorization

Complete all of the following. The form captures clinical, device, and billing information needed to support TMS authorization.

Information requested to support TMS authorization

Request is for TMS of the brain
Checkbox Yes/No
Request is for theta burst stimulation (TBS)
Checkbox Yes/No
Treatment parameters use HF-rTMS or LF-rTMS (frequencies <1 Hz to 20 Hz)
Checkbox Yes/No; specify protocol (e.g., HF to left DLPFC)
Has the patient previously received TMS in the past 30 days? If yes, provide prior auth number
Checkbox Yes/No; prior authorization number field
Age and diagnosis requirements
- Individual is 18 years or older>= 18
  Checkbox Yes/No; record current age/Date of birth
- Confirmed diagnosis of severe treatment-resistant major depressive disorder (MDD) — single or recurrent episode
  Checkbox Yes/No; list ICD-10-CM codes
- Individual has responded inadequately to pharmacotherapy with trials from two or more antidepressant classes (adequate dose and duration OR documented adherence OR inability to tolerate two trials)
  Checkbox Yes/No; provide medication trials with dates/doses/duration/outcome/adherence
Member responded to initial TMS treatment (50% reduction by standardized rating scale with subsequent clinically meaningful recurrence)
Checkbox Yes/No; provide initial and best response scores and dates
Provide standardized rating scales used to measure depressive symptoms (initial score/date and final score/date)
Provide standardized scales and scores with dates
TMS will be administered by an FDA-approved device — specify device name
Checkbox Yes/No; device name field
Standard treatment course will not exceed 5 days/week for 6 weeks (30 sessions) followed by taper
Checkbox Yes/No; requested start date and number of sessions/units
Implanted magnetic-sensitive device or metal items within 30 cm of the TMS coil (list device types)
Checkbox Yes/No; if yes, select specific device(s) and specify distance
Is this request for maintenance TMS treatment? (treatment after remission)
Checkbox Yes/No; define remission status and duration
Is this request for continuation treatment? (post-acute, up to 6 months)
Checkbox Yes/No
Individual has current or recent history of active suicidal ideation; ECT completed or considered
Checkbox Yes/No; document ECT consideration/completion
Individual has had previous psychotherapy — specify modalities and dates
Checkbox Yes/No; e.g., CBT, dates
Is member currently taking a benzodiazepine?
Checkbox Yes/No; document agent and dose
Request is for bilateral rTMS; if yes, has a unilateral treatment course been completed?
Checkbox Yes/No for bilateral request and unilateral completion
Specify protocol being used (e.g., HF-rTMS to left DLPFC; include HF/LF/TBS parameters)
Free-text protocol field; include treatment parameters
List all current diagnoses (ICD-10-CM)
ICD-10 codes required
Billing codes requested on form: CPT 90867 (initial including mapping) and CPT 90868 (subsequent delivery per session)
Requested start date and number of sessions/units for each code; include both code entries as shown on form

The form captures detailed clinical information including medication trials for the current or previous depressive episode (medication name, dates of trial, maximum dose, duration, outcome, side-effects, and adherence), standardized rating scales with initial and final scores and dates, device information and proximity of any implanted metal or magnetic-sensitive devices to the coil, treatment parameters (high-frequency, low-frequency, or theta-burst stimulation with target and session details), and optional attachments such as TMS intake evaluations or full psychiatric evaluations performed within three months of the requested start date.

Requested billing codes on form

Requested CPT codes on formCPT

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

Billing Rule

Specify number of sessions

Indicate requested start date and number of sessions/units for CPT codes 90867 and 90868 on the form.

Submission, documentation, and reporting requirements

Prior Authorization

Submit completed TMS Request Form

Fax the completed TMS Request Form to 877-521-4780 (toll-free) or submit via Availity. Include all required clinical fields on the form and provide medication trial details, standardized rating scales (with scores and dates), device information, and the requested CPT codes.

Documentation Required

Document medication trials and rating scales

Provide detailed medication trials for the current or previous episode: date of trial, maximum dose, duration, outcome, side-effects, adherence, and other relevant information. Also include standardized depression rating scales with initial and final scores and dates to document treatment-resistance and response.

Documentation Required

Report implanted devices and metal proximity

Report any implanted magnetic-sensitive medical device or other metal located less than or equal to 30 centimeters from the TMS coil; specify the device type. Note that dental amalgam fillings are not affected by the magnetic field and are acceptable for use with TMS. See device list on the form (e.g., cochlear implant, ICD, pacemaker, VNS, deep brain stimulator, aneurysm clips/coils/staples/stents, other).

Documentation Required

Attach supporting psychiatric evaluations

You may submit a copy of the TMS intake evaluation or a full psychiatric evaluation performed within three months of the requested start date to support the authorization. Additional documentation does not substitute for completing all required fields on the form.

Billing Rule

Specify number of sessions

Indicate the requested start date and the number of sessions/units for CPT 90867 (initial) and CPT 90868 (subsequent) on the form.

Key definitions on the form

Maintenance treatment: Treatment that continues after remission has been achieved. The form defines remission as no significant signs or symptoms of major depression for at least two months.

Continuation treatment: A course that begins after the acute/index course, lasts up to six months, and is designed to prevent worsening of symptoms and continue treatment for a depressive episode that has not yet remitted.

Member responded to initial treatment: Previous response to TMS shown by a 50% reduction in severity relative to pretreatment symptoms on a standardized rating scale AND recurrence based on clinically meaningful worsening relative to the best TMS response.

Policy Summary

PayerAnthem Blue Cross (California)

PolicyTranscranial Magnetic Stimulation Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review DateAug 1, 2025

SourceLink

On This Page

OpenPayer

Transcranial Magnetic Stimulation Request Form

TMS Authorization Request Form — At-a-Glance

Information requested to support TMS authorization

Requested billing codes on form

Submission, documentation, and reporting requirements

Key definitions on the form

Revision timeline