CurrentAnthemPolicy N/A

Transcranial Magnetic Stimulation (TMS) Request / Coverage Criteria

This document is an Anthem TMS request/authorization form that governs prior authorization and clinical information collection for TMS services (including retreatment, continuation, and maintenance) primarily for depressive disorders and other listed indications; it affects providers requesting coverage for TMS for Anthem members.

Policy Summary

PayerAnthem

PolicyTranscranial Magnetic Stimulation (TMS) Request / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization using the TMS request form including member identifiers, requested start date, number of sessions, and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30standard acute treatment sessions (maximum over 6 weeks)

3-week taperpost-acute tapering schedule (3, 2, 1 sessions by week)

90867-90869CPT codes listed on the form

>=18minimum age criterion listed

Coverage Criteria for TMS

Initial coverage criteria

Covered when ALL of the following are met for treatment‑resistant major depressive disorder (MDD):

Age: Individual is 18 years or olderage >= 18

listed as a required checkbox on form

Diagnosis: Confirmed diagnosis of treatment‑resistant major depressive disorder (MDD) (single or recurrent episode)

form checkbox

Medication trials: Inadequate response to pharmacotherapy despite adequate duration and dosage, documented adherence, trials from 2 or more classes of medications, or inability to tolerate pharmacotherapy as evidenced by 2 trials with documented side effects>=2 medication classes failed or intolerance documented

Policy Summary

PayerAnthem

PolicyTranscranial Magnetic Stimulation (TMS) Request / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization using the TMS request form including member identifiers, requested start date, number of sessions, and supporting clinical documentation.

SourceLink

On This Page

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form requests detailed medication trial history (dates, doses, duration, outcomes, side‑effects, adherence)

Device and parameters: TMS will be administered by a U.S. FDA‑approved device for the treatment of MDD using specified manufacturer stimulation parametersuse FDA‑approved device

device field on form

Treatment course limits: Standard treatment course not to exceed 5 days/week for 6 weeks (total of 30 sessions) followed by a 3‑week taper (3, then 2, then 1 session)<=30 acute sessions plus specified taper

explicit treatment course described on form

Safety exclusions: No active seizure disorder (except ECT‑induced or isolated febrile seizures in infancy), no acute or chronic psychotic symptoms in the current depressive episode, and no neurological conditions that increase risk (epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, primary or secondary CNS tumors)no listed contraindications present

checkboxes capture these exclusions

Substances lowering seizure threshold: No current use of substances that may significantly lower seizure threshold (for example, alcohol, stimulants)no such substances in current use

form includes checkbox

Implanted magnetic‑sensitive devices: No implanted magnetic‑sensitive medical device located ≤30 cm from the TMS coil (examples: cochlear implant, ICD, pacemaker, VNS, deep brain stimulator, metal aneurysm clips/coils/staples/stents) unless specifically assessedabsence or careful assessment if present

form lists devices to check

Retreatment

Retreatment coverage criteria (distinct group):

Prior response: Previous response to TMS demonstrated by ≥50% reduction in severity on a standardized rating scale compared with pretreatment>=50% improvement vs pretreatment

definition of retreatment on form; prior authorization number for previous treatment requested if available

Recurrence of depression demonstrated by clinically meaningful worsening of symptoms relative to the best TMS response on a standardized rating scaleclinically meaningful worsening

both prior response and recurrence required for retreatment

Maintenance/Continuation definitions

Maintenance and continuation definitions (administrative criteria):

Maintenance treatment continues after remission is achieved; remission refers to virtual absence of depressive symptoms for at least 3 weeksremission >= 3 weeks

form defines maintenance

Continuation treatment begins after the acute/index course and may last up to 6 months to prevent worsening and continue treatment for an episode that has not yet remitted<= 6 months

form defines continuation

Requests for theta burst stimulation (TBS) are explicitly identified on the TMS request form as not medically necessary for all indications. The form states this directly on the cover instructions and again in the checklist, which should be taken as the policy stance when submitting prior authorization requests.

The form also lists clinical and device-related contraindications and safety concerns that must be considered for any TMS request, including active seizure disorder, psychotic symptoms in the current episode, certain neurologic conditions, implanted magnetic-sensitive devices within ≤30 centimeters of the TMS coil, and current use of substances that may significantly lower the seizure threshold; these items reinforce the exclusionary context in which TBS is not supported.

Theta burst stimulation (TBS) is stated repeatedly on the form as considered not medically necessary (NMN) for all indications. Providers seeking authorization should not request TBS using this form because such requests will not meet the medical necessity criteria.

Because the form requires detailed documentation of diagnosis, prior treatment failures, device and parameter specification, and safety screening, any request for TBS would be inconsistent with the documented coverage criteria and the explicit NMN statement on the request form.

Coding and Visit Limits

TMS CPT CodesCPTCovered

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

Standard acute treatment course — session frequency and taper schedule

Acute session frequencyUp to 5 days per week for up to 6 weeks (maximum 30 acute sessions)

Post-acute taper schedule3-week taper following acute course: 3 sessions in week 1, 2 sessions in week 2, 1 session in week 3

Total sessions including taper30 acute sessions plus the 3-week taper as specified

TMS sessions — acute session limit and taper summarized

Acute session limitMaximum of 30 acute sessions over a 6-week period

Taper summary3-week taper after acute course: 3, then 2, then 1 session per week

Weekly frequency during acute phaseUp to 5 sessions per week

Provider Requirements and Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for transcranial magnetic stimulation (TMS). Use the Transcranial Magnetic Stimulation Request form and include complete member identifiers and prior authorization details to assist timely review. Fax completed form to 866-834-7469 (toll-free) or submit per payer instructions.

Include member name, ID number, DOB and current age
Provide requesting TMS office and physician information (name, phone, fax, NPI, Tax ID)
Attach prior authorization number if request is for retreatment

Documentation Required

Medication Trial Documentation Required

Document all antidepressant medication trials tried for the current or previous depressive episode. For each trial, provide dates, maximum dose, duration, documented adherence, outcomes (response or lack thereof), and any intolerable side effects. Ensure trials include agents from at least two different medication classes unless there is documented intolerance or contraindication.

List each medication trial with: medication name, start and end dates, maximum dose, duration of trial, outcome/response, side-effects, adherence information

Documentation Required

Required Documentation

Complete all required sections of the TMS request form. At minimum, include standardized rating scale scores (initial and final with dates), diagnosis and age confirmation, device (if applicable), seizure/psychosis/neurologic history, requested start date, and number of sessions/units. You may optionally submit the TMS intake evaluation or a full psychiatric evaluation performed within 3 months of the requested start date to support medical necessity.

Standardized depression rating scale initial and final scores with dates
Confirmation of treatment-resistant MDD criteria and medication trial summaries
Requested start date and total number of sessions (standard course: up to 30 sessions over 6 weeks plus taper)
Optional: intake or psychiatric evaluation within 3 months

Denial Risk

Theta Burst Stimulation (TBS) Not Covered

Theta burst stimulation (TBS) requests are considered not medically necessary and will be denied. Do not submit TBS as an alternative modality for covered TMS indications.

TBS (theta burst stimulation) is considered not medically necessary for all indications

Level of Care — Outpatient Criteria

Outpatient

Indication: Treatment‑resistant MDD meeting medication trial, diagnostic, and age requirements (see initial coverage criteria)see initial coverage criteria

form captures admission‑level info

Treatment response monitoring: Provide standardized rating scales with initial and final scores and dates to document responsedocumented scores before and during/after treatment

form includes fields for initial and final standardized scores

Treatment Modalities Covered / Not Covered

TMS

TMS modality: Therapeutic repetitive TMS using U.S. FDA‑approved devices for MDD delivered per manufacturer parametersFDA‑approved device and parameters

form requires specifying device and lists CPT codes 90867, 90868, 90869

Definitions

Retreatment definition — prior response requirement and recurrence criteria

Prior response requiredPrevious response to TMS demonstrated by ≥50% reduction in severity on a standardized rating scale compared with pretreatment

Recurrence requirementRecurrence of depression defined as clinically meaningful worsening of symptoms relative to best TMS response on a standardized rating scale

Authorization for prior treatmentIf retreatment, provide prior authorization number for the previous TMS course when available

Maintenance treatment — definition and remission duration threshold

Maintenance definitionTreatment that continues after remission has been achieved

Remission thresholdRemission = virtual absence of depressive symptoms for at least 3 weeks

Maintenance purposeTo continue treatment after remission and may end with relapse or recovery

Continuation treatment — definition, duration up to 6 months and purpose

Continuation definitionCourse that begins after the acute/index course and is designed to prevent worsening and continue treatment for an episode not yet remitted

Maximum durationLasts up to 6 months

PurposeTo prevent symptom worsening and continue treatment when remission has not been achieved after the acute course

Background and Scope

This TMS request form is intended to obtain prior authorization for transcranial magnetic stimulation primarily for treatment‑resistant major depressive disorder (MDD) in adults. It captures essential clinical information including standardized rating scale scores (initial and final), confirmation of a diagnosis of treatment‑resistant MDD, and verification that the individual is at least 18 years of age.

The form documents required evidence of inadequate response to pharmacotherapy — specifically trials from two or more medication classes with adequate dose and duration and documented adherence, or documented intolerance demonstrated by two trials with side effects — and requires specification of the FDA‑approved device and stimulation parameters to be used. It also records the intended treatment course limits (up to 30 sessions over 6 weeks with a 3‑week taper) and screens for safety exclusions (seizure history, psychotic symptoms, neurologic conditions, implanted magnetic‑sensitive devices, and substance use that lowers seizure threshold).