CurrentAnthemPolicy N/A

Transcranial Magnetic Stimulation Request

This document is an Anthem Transcranial Magnetic Stimulation (TMS) Request form used to collect clinical, device, diagnosis, and treatment-history information to support prior authorization/utilization management review for TMS services. It captures eligibility, treatment history, contraindications, device, session counts, and billing CPT codes.

Policy Summary

PayerAnthem

PolicyTranscranial Magnetic Stimulation Request

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionComplete all sections of the TMS Request form, provide standardized rating scale scores and medication trial details, and submit any full psychiatric evaluation within 3 months of the requested start date.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — the form documents criteria and processes for TMS prior authorization but does not introduce substantive policy changes.

3Key CPT codes listed

30Standard maximum acute sessions

50%Retreatment response threshold

Document overview

This is an Anthem Transcranial Magnetic Stimulation (TMS) Request form used to collect clinical, device, diagnostic, and treatment‑history information to support prior authorization/utilization management review for TMS services. The form records eligibility and clinical elements (for example: intent of request such as acute/index, continuation, maintenance, or retreatment; diagnostic target including treatment‑resistant major depressive disorder (MDD) or other specified conditions; prior medication trials with dates/doses/duration/outcomes; standardized rating scale scores and response; seizure risk factors; and implanted magnetic‑sensitive device proximity and device specification) and lists the relevant CPT codes (90867, 90868, 90869).

The form is informational and used to document clinical criteria for review rather than to itself make a coverage determination. It documents checkboxes and thresholds used in utilization review — for example, the retreatment response threshold of 50% reduction on a standardized rating scale, the standard acute course limit of up to 5 days/week for 6 weeks (total 30 sessions) with a 3‑week taper, and the implant proximity exclusion of devices ≤ 30 cm from the TMS coil — and notes that theta burst stimulation (TBS) is considered not medically necessary (NMN) for all indications.

Quick facts and thresholds

Standard maximum acute sessionsUp to 5 days/week for 6 weeks (total 30 sessions) followed by a 3‑week taper: 3 sessions in week 1, 2 sessions in week 2, 1 session in week 3

Retreatment response thresholdPrevious response defined as ≥50% reduction in severity relative to pretreatment MDD symptoms on a standardized rating scale

Retreatment proximity threshold (implants <=30 cm)Implanted magnetic‑sensitive medical device located less than or equal to 30 centimeters from the TMS coil is captured as an exclusion/consideration

CPT codes listed on form90867, 90868, 90869 (3 codes)

Theta burst stimulation (TBS)Listed on form as considered Not Medically Necessary (NMN) for all indications

Billing codes referenced on the form

TMS CPT codes listed 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
90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management

What providers must do

Documentation Required

Complete authorization form and submit supporting records

Complete all sections of the TMS Request form and submit supporting records: include standardized rating scale scores (initial and final), list medication trials with dates, maximum doses, duration, outcomes, side-effects, and adherence; and submit a full psychiatric evaluation completed within 3 months of the requested start date.

Standardized rating scale scores (initial and final)
List medication trials with dates/doses/duration/outcomes/side-effects/adherence
Submit full psychiatric evaluation within 3 months of requested start date

Prior Authorization

Fax completed form for prior authorization

Fax the completed TMS Request form to 866-834-7469 to initiate timely review and prior authorization.

Fax number: 866-834-7469 (toll-free) — fax completed form for timely review

Documentation Required

Device and stimulation parameters

Document on the form that TMS will be delivered by a U.S. FDA–approved device for treatment of MDD; specify the device name on the form and indicate that stimulation parameters will follow the manufacturer's user manual.

Document U.S. FDA approved device for MDD
Specify device name on the form
State that manufacturer's stimulation parameters will be followed

Documentation Required

Retreatment authorization linkage

For retreatment requests, provide the previous authorization number (if available) and documentation showing prior response to TMS (at least a 50% reduction in severity on a standardized rating scale) plus evidence of recurrence/worsening relative to best TMS response.

Provide previous authorization number for prior treatment (if available)
Documentation of prior response (>=50% reduction on standardized rating scale)
Evidence of recurrence/clinically meaningful worsening relative to best TMS response

Definitions and terms used on the form

Definitions

RetreatmentDefined as prior response to TMS (50% reduction in severity on a standardized rating scale) and recurrence of depression based on clinically meaningful worsening relative to best TMS response

Maintenance treatmentTreatment that continues after remission; remission is virtual absence of depressive symptoms for at least 3 weeks

Continuation treatmentCourse after the acute/index course lasting up to 6 months to prevent worsening of symptoms for an episode that has not remitted

Theta burst stimulation (TBS)Noted on the form as considered Not Medically Necessary (NMN) for all indications

Policy Summary

PayerAnthem

PolicyTranscranial Magnetic Stimulation Request

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Transcranial Magnetic Stimulation Request

Document overview

Form criteria and checkbox logic

Billing codes referenced on the form

What providers must do

Definitions and terms used on the form

Document revision history