CurrentAnthemPolicy N/A

Transcranial Magnetic Stimulation (TMS) prior authorization request

A TMS Request Form used by Anthem to collect clinical and administrative information required to authorize TMS for individuals (primarily for major depressive disorder) including prior treatment trials, contraindications, device and stimulation parameters, and supporting documentation.

Policy Summary

PayerAnthem

PolicyTranscranial Magnetic Stimulation (TMS) prior authorization request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete and fax the Transcranial Magnetic Stimulation Request Form with clinical details to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 sessionsmanufacturer/FDA specified treatment course

>=4pharmacologic trials required

2+augmentation therapies required

Adultpatient age

Coverage criteria for TMS prior authorization

Policy Summary

PayerAnthem

PolicyTranscranial Magnetic Stimulation (TMS) prior authorization request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete and fax the Transcranial Magnetic Stimulation Request Form with clinical details to request authorization.

SourceLink

On This Page

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Primary eligibility: Individual is an adult and TMS is requested for treatment of major depressive disorder (MDD)

form asks to confirm adult status and indication

Pharmacologic treatment history: Documented failure to significantly respond to prior treatment: either four trials of psychopharmacologic agents in the current depressive episode OR inability to tolerate pharmacologic agents as evidenced by four trials with distinct side effects; trials should include at least two different agent classes at or above the minimum effective dose and duration

form requires four trials or intolerance and two agent classes at effective dose/duration

Augmentation therapies: Treatment trials have included at least two evidence-based augmentation therapies

augmentation therapy defined on form

Prior positive TMS response: If history of prior TMS, documented greater than 50% improvement on a standardized depressive symptom rating scale>50% improvement

form asks for rating scale and result

Psychotherapy: Trial of an evidence-based psychotherapy known to be effective for MDD with adequate frequency and duration that did not result in significant improvement

form requests psychotherapy model, frequency/duration, and outcomes

Documentation of severity: Depressive symptoms documented by a standardized rating scale that reliably measures depressive symptoms with provided scores (e.g., BDI, GDS, HAMD, IDS-SR, MADRS, PHQ-9, QIDS)

acceptable scales listed on form

Device and parameter conformity: Proposed treatment is to be administered using an FDA-approved TMS device and consistent with the manufacturer's/FDA specified stimulation parameters unless justification provided30 sessions + 3-week taper

form asks if proposed treatment matches specified parameters (5 days/week x 6 weeks then 3-week taper)

Absolute exclusions: No active seizure disorder (except ECT-induced or isolated febrile seizures in infancy without recurrence), no acute or chronic psychotic symptoms/disorders in the current depressive episode, and no disqualifying neurological conditions (epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or CNS tumors); no implanted magnetic-sensitive medical device located <= 30 cm from the TMS coil unless documented as safe

form lists these contraindications and implanted device proximity

The policy identifies several clinical conditions that are contraindications to TMS and may lead to denial or further review. Specifically, active seizure disorder or a history of seizure (excluding ECT-induced seizures or isolated febrile seizures in infancy without recurrence) is listed as an exclusion. Acute or chronic psychotic symptoms or psychotic disordersneurological conditions — including epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, a history of repetitive or severe head trauma, or primary/secondary CNS tumors — are noted as exclusionary clinical risks for TMS.

The form requires that providers confirm whether an implanted magnetic-sensitive medical device or other metal items are present within ≤ 30 centimeters of the TMS magnetic coil, because devices in that proximity may preclude safe treatment. Examples called out include cochlear implants, implanted cardioverter defibrillators (ICD), pacemakers, vagus nerve stimulators (VNS), and metal aneurysm clips/coils, staples, or stents. The form also notes that dental amalgam fillings are not affected and are acceptable for use with TMS.

Requests for members who have any of the contraindicated clinical conditions or who have incompatible implanted devices located within the specified proximity are considered not appropriate unless documentation demonstrates that the risk has been mitigated or the device is safe relative to the proposed stimulation. In practice, this means authorization is unlikely without clear, supporting evidence addressing the contraindication or explicit documentation that the implanted device is not affected by the TMS magnetic field.

Treatment course and coding-relevant details

Standard TMS treatment course — schedule summary

Standard course schedule5 days/week for 6 weeks (total 30 sessions), followed by a 3-week taper: 3 sessions first taper week, 2 sessions second taper week, 1 session final week.

Manufacturer/FDA alignmentTreatment must be administered using an FDA‑approved device according to the manufacturer's manual and specified stimulation parameters (above).

Documentation question on formForm asks: 'Is the proposed treatment consistent with these parameters? Yes/No' and requests number of units per week.

What providers must submit and document

Prior Authorization

Prior authorization submission — complete and fax the TMS Request Form with clinical details

Prior authorization submission — complete and fax the Transcranial Magnetic Stimulation (TMS) Request Form with all clinical details to the fax number on the form.

Fax completed TMS Request Form to 844-430-1703
Include member identifiers (name, ID, DOB) and provider signature/date

Step Therapy

Required prior medication and augmentation trials — documentation of multiple medication trials / augmentation therapies

Required prior medication and augmentation trials — document medication history and augmentation attempts. The request must show multiple antidepressant trials and evidence-based augmentation therapies at adequate dose and duration, or intolerance to pharmacotherapy.

List all medication trials for the current depressive episode (agent, maximum dose, duration, outcome, side effects)
Document at least two antidepressant classes tried at minimum effective dose/duration or two evidence-based augmentation therapies
If intolerant, document four distinct trials with associated side effects

Documentation Required

Submission and supporting records — intake evaluation or full psychiatric evaluation within timeframe and supporting materials

Submission and supporting records — include clinical evaluations and supporting documentation. Attach a recent TMS intake evaluation or a full psychiatric evaluation within 3 months of the requested start date, and any additional records that support the request.

Attach TMS intake evaluation or full psychiatric evaluation within 3 months of requested start date
Include documentation of prior treatments, psychotherapy notes, and standardized rating scale results

Documentation Required

Clinical measurement and trial documentation — standardized depression scale results and psychotherapy/medication trial documentation

Clinical measurement and trial documentation — provide standardized rating-scale scores and psychotherapy/medication trial results. Document the rating scale used, score and interpretation, psychotherapy modality, frequency/duration, and lack of clinically significant improvement.

Specify which standardized scale was used (e.g., PHQ-9, MADRS, HAMD, BDI, GDS, IDS-SR, QIDS) and report the score and date
Document psychotherapy trial (model, frequency, duration) and outcome
Document medication trial outcomes (response, nonresponse, side effects)

Denial Risk

Contraindications / clinical exclusion risks — presence of seizure disorder, psychosis, neurological diseases as denial-risk triggers

Contraindications and exclusion risks — identify any conditions that may preclude TMS. Presence of seizure disorder, acute or chronic psychosis in the current episode, or certain neurological conditions are denial-risk triggers and must be reported.

Report any history of seizures (unless limited to specified exceptions)
Report current psychotic symptoms or diagnoses
Report neurological conditions (epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, CNS tumors, history of severe/repetitive head trauma)

Denial Risk

Implanted device proximity — implanted magnetic-sensitive devices within 30 cm of coil as denial-risk / exclusion

Implanted device proximity — disclose any implanted magnetic‑sensitive medical device located ≤30 cm from the TMS coil. Devices within this distance are exclusion risks; list device type and distance from coil.

Indicate presence of implanted magnetic‑sensitive devices and specify type (e.g., cochlear implant, ICD, pacemaker, VNS, aneurysm clips/stents)
State distance from TMS coil (≤30 cm is a contraindication)
Note that dental amalgam fillings are acceptable

Background and scope

Background: This request form is focused on authorizing transcranial magnetic stimulation (TMS) for individuals with major depressive disorder (MDD). It requires documentation that the member has had an inadequate response or intolerance to prior treatments, including multiple medication trials and evidence-based augmentation strategies, and that depressive symptom severity has been documented using a standardized rating scale. The proposed treatment must follow an FDA-approved device and the manufacturer's specified stimulation parameters (the standard course described elsewhere in the form).

OpenPayer

Transcranial Magnetic Stimulation (TMS) prior authorization request

Coverage criteria for TMS prior authorization

Treatment course and coding-relevant details

What providers must submit and document

Definitions and key terms

Outpatient level-of-care criteria

Available treatment modalities referenced

Visit limits and session counts

Background and scope