CurrentAnthemPolicy MULTI-BCBS-CM-089115-25-SRS89115

Transcranial Magnetic Stimulation (TMS) request form

A provider-facing request/authorization form for outpatient transcranial magnetic stimulation (TMS) therapy used to document clinical information, prior treatments, device type, and treatment parameters for Anthem members in specified states.

Policy Summary

PayerAnthem

PolicyTranscranial Magnetic Stimulation (TMS) request form

Policy CodePolicy MULTI-BCBS-CM-089115-25-SRS89115

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including prior antidepressant trials (dates, doses, duration, outcomes), standardized depression rating scale scores with dates, device and treatment parameters, and requested number of sessions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30standard maximum course (5/week for 6 weeks)

≥18age threshold for acute severe MDD request

2+minimum antidepressant classes tried

90867/90868CPT codes listed

Coverage Criteria for TMS

Policy Summary

PayerAnthem

PolicyTranscranial Magnetic Stimulation (TMS) request form

Policy CodePolicy MULTI-BCBS-CM-089115-25-SRS89115

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Age and diagnosis: Individual is 18 years or older with a confirmed diagnosis of severe treatment-resistant major depressive disorder (single or recurrent episode).age >=18

Prior pharmacotherapy failure: Inadequate response to pharmacotherapy despite antidepressant trials with two or more classes with adequate dose and duration, or documented adherence, or inability to tolerate two trials with documented side effects; details of trials (dates, maximum dose, duration, outcome, side-effects, adherence) must be provided on the form.>=2 classes

Form includes fields to list medication trials with date, dose, duration, outcome, side-effects, adherence.

Device and protocol documentation: Planned treatment documented as TMS or theta burst stimulation (TBS) with treatment parameters specified (HF-rTMS or LF-rTMS frequency) and indication whether an FDA-approved device will be used; if FDA-approved device marked, device must be specified.device specified

Form asks to specify device if FDA-approved.

Treatment course limits: Standard initial course will not exceed five sessions per week for six weeks (total of approximately 30 sessions), followed by a taper as indicated; requested number of sessions and start date must be provided.<=30 sessions initial

Form states standard course = five/week for six weeks (total of 30 sessions) and requests number of sessions/units and start date.

Safety screening: No implanted magnetic-sensitive medical device or metal within <=30 centimeters of the TMS magnetic coil unless disclosed and reviewed; specific devices (cochlear implant, ICD, pacemaker, VNS, DBS, metal aneurysm clips/coils/staples/stents) must be indicated if present (dental amalgam fillings acceptable).distance >30 cm or listed and reviewed

Form asks whether such devices are present and lists device types that must be reported.

Treatment context flags: Form documents whether request is for maintenance treatment, continuation treatment, or an acute episode; whether patient received TMS in the past 30 days and prior response to TMS (including standardized rating scale initial and final scores with dates).

Definition of prior response: >=50% reduction on a standardized rating scale and recurrence as clinically meaningful worsening; form captures initial and final scores and dates.

The form requires screening for implanted magnetic-sensitive medical devices located ≤30 centimeters from the TMS magnetic coil. Specific items listed include a cochlear implant, implanted cardioverter defibrillator (ICD) within 30 cm, pacemaker within 30 cm, vagus nerve stimulator (VNS), deep brain stimulator, and metal aneurysm clips/coils/staples/stents within 30 cm. Dental amalgam fillings are explicitly noted as acceptable. Presence of any such implanted device or metal within ≤30 cm must be disclosed and will require review for safety and may preclude treatment or necessitate additional evaluation prior to approval.

Requests must document prior pharmacotherapy attempts. The form requires documentation that the individual has had inadequate response to antidepressant trials from two or more classes with details on adequacy (dose and duration), documented adherence, or inability to tolerate two trials with documented side effects. Incomplete documentation of these prior adequate medication trials or missing standardized depression rating scale scores (initial and final with dates) may result in denial or delay of authorization.

The submitted form should include standardized rating scale scores (initial and final) with dates to demonstrate baseline severity and treatment response; absence of these scores and dates undermines the evidence needed to support medical necessity for TMS.

Coding and Session Limits

TMS CPT CodesCPT

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

Standard course sessions — initial TMS

Standard course (sessions)30 sessions (5 per week for 6 weeks)

Weekly frequencyUp to 5 sessions per week

Typical duration6 weeks for the initial standard course

TaperingFollowed by taper as indicated (taper days to be specified on form)

Provider Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization must be requested using the TMS prior authorization form. Fax the completed form to 866-834-7469 (toll-free) or submit it via Availity. Include the relevant CPT codes for the requested services (90867 for the initial session including cortical mapping/motor threshold determination and 90868 for subsequent per-session delivery and management). Provide requested start date and number of sessions/units for each CPT code submitted.

Fax: 866-834-7469 (toll-free)
Online: Availity submission
CPT: 90867 (initial); 90868 (subsequent)

Step Therapy

Required Prior Medication Trials

Required prior medication trials must be documented on the form for the current or previous depressive episode. For each trial provide medication name, date of trial, maximum dose, duration, outcome, side effects, and documentation of adherence or reasons for intolerance when applicable. The policy requires trials of two or more antidepressant classes unless there is documented intolerance or contraindication.

List each medication trial with: date, max dose, duration, outcome, side effects, adherence
Document trials of ≥2 antidepressant classes or explain intolerance/contraindication

Documentation Required

Required Submission Materials

Required submission materials — complete all sections of the TMS authorization form. Include member demographics, prescriber/TMS center information, diagnoses (ICD-10), requested CPT codes with start date and number of sessions, standardized depression rating scale scores (initial and final with dates), documentation whether treatment is acute/continuation/maintenance, device type (if FDA-approved device is used), and any relevant psychiatric or TMS intake evaluations performed within three months.

Member demographics and contact information
Prescriber and TMS center information
ICD-10 diagnosis(es)
Requested CPT codes (90867, 90868), start date, number of sessions/units
Standardized rating scales: initial score, final score, dates
TMS device specification (if applicable)
Attach TMS intake evaluation or full psychiatric evaluation (within 3 months) — optional but recommended

Denial Risk

Documentation Insufficiency — Risk of Denial or Delay

Documentation insufficiency may lead to denial or requests for additional information. Incomplete prior medication trial details, missing standardized rating scale scores or dates, absent CPT/session details, or omission of prescriber/TMS center information are common reasons for return of the request or denial. Ensure all fields on the form are completed and supplemental evaluations are attached when relevant.

Incomplete prior trials (missing dates, dose, duration, outcome) risks denial
Missing standardized rating scale scores or dates may prompt additional info requests
Omitted CPT codes, start date, or session counts may delay authorization

Background

This form is used to request outpatient transcranial magnetic stimulation (TMS), including theta burst stimulation (TBS), for patients with major depressive disorder (MDD), specifically acute, severe, or treatment-resistant episodes. It captures whether the request is for an acute episode, continuation, or maintenance treatment, documents device type (including whether an FDA‑approved device will be used), planned treatment protocol (HF‑rTMS, LF‑rTMS, or TBS), and whether the patient received TMS in the prior 30 days.

The form also documents clinical eligibility elements required for an initial course: confirmation that the individual is ≥18 years old, diagnosis of severe treatment‑resistant MDD, and evidence of inadequate response to ≥2 antidepressant classes (with dose, duration, outcomes, side effects, and adherence recorded). It requests standardized depression rating scale scores (initial and final with dates) to establish baseline severity and response, and it specifies the standard initial treatment course limit of 30 sessions (five per week for six weeks) with tapering as indicated.

Definitions

Maintenance treatment — definition and criteria for remission

DefinitionMaintenance treatment: treatment that continues after remission has been achieved

Full remission standardNo significant signs or symptoms of major depression for at least two months

Form requirementForm asks whether the request is for maintenance TMS treatment and documents remission status

DocumentationProvide standardized rating scale scores and dates to support remission and need for maintenance

Previous response to TMS — definition

Response thresholdPrior response defined as ≥50% reduction in symptom severity on a standardized rating scale compared with pretreatment

Recurrence criterionRecurrence defined by clinically meaningful worsening of symptoms relative to the best TMS response on a standardized rating scale

Form dataForm requests the standardized rating scales used, initial and final scores, and dates to document prior response

OpenPayer

Transcranial Magnetic Stimulation (TMS) request form

Coverage Criteria for TMS

Coding and Session Limits

Provider Submission & Documentation Requirements

Background

Definitions

Level of Care

Treatment Modalities

Visit Limits