CurrentAnthem Blue CrossPolicy N/A

Request for Authorization: Transcranial Magnetic Stimulation Request

Authorization request form and checklist for transcranial magnetic stimulation (TMS) services for Anthem Blue Cross Medi-Cal Managed Care members in California. Captures member/provider data, treatment parameters, clinical criteria for acute, continuation, and maintenance TMS, device and contraindication screening, medication trial history, and CPT codes to request.

Policy Summary

PayerAnthem Blue Cross

PolicyRequest for Authorization: Transcranial Magnetic Stimulation Request

Policy CodePolicy N/A

Change TypeAuthorization form; no material coverage changes

Effective Date

Next Review Date

Key ActionProviders must submit the completed TMS authorization form (via Availity preferred or fax to 800-991-6045) including member/provider details, treatment parameters, medication trial history, standardized rating scale scores, and device information.

POLICY UPDATE CHANGES

No material clinical or coverage changes to the policy (authorization form/checklist only).

3Primary CPT codes listed

30Typical acute course (max sessions)

2+Antidepressant classes required

Coverage Summary

This is an authorization request form and checklist for transcranial magnetic stimulation (TMS) services for Anthem Blue Cross Medi‑Cal Managed Care members in California. The form captures member and provider administrative data, requested TMS CPT codes (90867, 90868, 90869) with frequency notes, treatment parameters (HF‑rTMS, LF‑rTMS, Theta burst option), device screening and proximity thresholds, medication trial history, standardized rating scale scores, and items needed to support coverage decisions for acute, continuation, and maintenance TMS indications.

Key clinical and administrative elements captured include: member/provider identifiers and contact details; requested CPT code, date span and units; confirmation of FDA‑approved device; documentation of prior TMS within 30 days or prior Anthem authorization; screening for implanted magnetic‑sensitive devices or metal within ≤ 30 centimeters of the coil; medication trial history (dates, max dose, duration, outcome, adherence, side effects); standardized depression rating scales with initial and most recent scores and dates; and attestation/signature and submission instructions (Availity preferred or fax).

The form explicitly requests the requested treatment intent (acute episode, continuation, or maintenance), documents required response criteria (including prior response defined as 50% reduction on a standardized rating scale), and notes the standard acute treatment course limit of up to five days per week for six weeks (total of 30 sessions), followed by a taper.

CPT Codes

TMS CPT codes (to request on form)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

Provider Actions & Submission Requirements

Prior Authorization

Submit completed TMS Authorization Form

Submit the completed TMS Authorization Form via Availity (preferred) or fax to 800-991-6045. The form must include member and provider details, requested TMS CPT codes and requested date span/units, treatment parameters (including TBS if applicable), device screening information, medication trial history, standardized rating scale scores (initial and most recent with dates), and device information.

90867
90868
90869

Documentation Required

Document medication trial history

Provide medication trial history for the current or previous depressive episode including dates of each trial, maximum dose, duration of trial, outcomes (including side effects), and documentation of adherence; this information is required to demonstrate inadequate response to pharmacotherapy.

Documentation Required

Provide standardized rating scales

Submit the standardized rating scale used to measure depressive symptoms and record the initial score with date and the most recent score with date to document response to treatment or recurrence.

Documentation Required

Device safety screening

Document presence or absence of implanted magnetic‑sensitive devices or other implanted metal located less than or equal to 30 centimeters from the TMS coil. If present, specify device types (e.g., cochlear implant, ICD, pacemaker, VNS, DBS, metal aneurysm clips/coils/staples/stents, or other) so unsafe devices can be identified prior to authorization.

Billing Rule

Frequency limits noted on form

Frequency limits for the listed CPT codes are noted on the form: 90867 is the initial TMS treatment code and is limited to one per treatment; 90868 is the subsequent per‑session delivery and management code (no fixed frequency limit on the form). When submitting, indicate the requested date span and requested units for each code.

90867
90868

Background

Background: This document is the Anthem Blue Cross Medi‑Cal Managed Care prior authorization request form for Transcranial Magnetic Stimulation (TMS) in California. It is used by providers to collect the clinical and administrative information required to support coverage decisions for TMS across acute, continuation, and maintenance treatment intents.

The form is intended to document member/provider details, treatment parameters, device safety screening, prior treatment/TMS response, medication trial history, standardized rating scale scores, and provider attestation — all of which are required elements for authorization review. Submission is via Availity (preferred) or fax as specified on the form.

Maintenance treatment: Treatment that continues after remission has been achieved; remission is defined on the form 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.

Response to initial treatment: Previous response to TMS defined as a 50% reduction in severity relative to pretreatment major depressive disorder symptoms as reported by a standardized rating scale.

Policy Summary

PayerAnthem Blue Cross

PolicyRequest for Authorization: Transcranial Magnetic Stimulation Request

Policy CodePolicy N/A

Change TypeAuthorization form; no material coverage changes

Effective Date

Next Review Date

On This Page

OpenPayer

Request for Authorization: Transcranial Magnetic Stimulation Request

Coverage Summary

Authorization / Medical Necessity Criteria

CPT Codes

Provider Actions & Submission Requirements

Background

Revision History