CurrentBeacon-Health-OptionsPolicy N/A

Repetitive Transcranial Magnetic Stimulation (TMS) Request/Form

A provider request form and clinical checklist for prior authorization of repetitive transcranial magnetic stimulation (TMS) for members with severe major depressive disorder; used by Beacon-Health-Options (Carelon) to evaluate clinical eligibility.

Policy Summary

PayerBeacon-Health-Options

PolicyRepetitive Transcranial Magnetic Stimulation (TMS) Request/Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request with clinician-attested criteria, psychiatrist face-to-face evaluation documentation, validated depression scale score and a 5-year psychotropic medication and psychotherapy history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10numbered form sections

3diagnosis code options listed

5lookback period (years)

PHQ-9, MADRSrequested depression scales

Coverage Criteria for TMS

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Initial Authorization Criteria

Covered when ALL of the following are met

Primary diagnosis: Member has confirmed diagnosis of severe major depressive disorder (F32.2 or F33.2).

See checkbox options on form.

Treatment resistance or intolerance: Member demonstrates resistance (lack of clinically significant response) to psychopharmacologic agents in the current episode OR inability to tolerate psychopharmacologic agents (intolerable side effects) OR is a candidate for and has declined electroconvulsive therapy (ECT) and TMS is considered a less invasive option.

Provider must document medication trials and responses.

Psychiatrist evaluation: Order for TMS written by a psychiatrist (MD or DO) who has examined the Member face-to-face and reviewed the record; documentation must be submitted.

Form requests attestation and supporting documentation.

Psychotherapy trial: Member had an adequate trial of evidence-based psychotherapy without significant improvement within the past 5 years OR reason why psychotherapy was not tried is documented.within past 5 years

Dates and type of psychotherapy requested on form.

Medication history: Complete psychotropic medication history for the past 5 years including dose, start/end dates, and response (improved, inadequate response, adverse, intolerability, non-adherence).5 years

Form provides medication tables for this purpose.

Depression severity: Most recent score on a validated self-report depression scale (PHQ-9, MADRS, BDI, HAM-D, GDS) provided with date.

Form requests scale name, score, and date.

Presence of an implanted magnetically sensitive device or other implanted metal items located less than or equal to ~30 cm from the TMS magnetic coil is an exclusion. Examples listed on the form include, but are not limited to: cochlear implant, implanted cardioverter defibrillator (ICD), pacemaker, vagus nerve stimulator (VNS), metal aneurysm clips/coils, staples, or stents.

The form states TMS is not medically necessary when contraindications or exclusionary clinical states are present. Specifically, TMS is not indicated for members with contraindicated implanted magnetic-sensitive devices or nearby metal items, active neurological conditions (as listed), uncontrolled seizure disorder or a history of seizures, current substance abuse, pregnancy or nursing, or a current suicidal plan or recent suicide attempt.

Diagnosis and Procedure Codes

Target ICD-10 DiagnosesICD-10Covered

F32.2	Major Depressive Disorder, Single Episode, Severe (Without Psychotic Features)
F33.2	Major Depressive Disorder, Recurrent Episode, Severe (Without Psychotic Features)

TMS CPT CodesCPT

90867	Initial TMS including cortical mapping, motor threshold determination, and delivery management
90868	Subsequent TMS delivery and management, per session
90869	Subsequent motor threshold redetermination with delivery and management

Psychotherapy and medication lookback — within past 5 years

Lookback period for psychotherapyEvidence-based psychotherapy trial without significant improvement within the past 5 years; dates requested on form.

Psychotropic medication history windowPsychotropic medications taken within the past five years — include medication name, dose, start/end dates, and response.

Required documentation elementsIf psychotherapy not attempted, reason must be documented; medication table on form captures response categories (improved, inadequate response, adverse, intolerability, non-adherence, other).

Purpose of lookbackDemonstrates prior adequate trials of psychotherapy and medications within past 5 years as part of treatment-resistance assessment for TMS eligibility.

Provider Requirements and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for TMS procedure CPT codes. Submit a completed prior authorization / TMS request form with clinician-attested criteria to request coverage for repetitive TMS (rTMS) services.

Affected codes: CPT 90867, 90868, 90869
Submit to payer per instructions on request form (fax/portal)

Documentation Required

Psychiatrist Face-to-Face Exam Documentation

A psychiatrist (MD or DO) must have examined the member face-to-face and reviewed the medical record prior to the TMS order. Include the psychiatrist’s evaluation note with the request form documenting the face-to-face exam and clinical rationale for TMS.

Attach psychiatrist face-to-face evaluation and record review documentation
Include diagnosis, current clinical status, and justification for TMS

Denial Risk

Insufficient Prior Treatment Documentation — Denial Risk

Document prior treatment history demonstrating an adequate trial of evidence-based psychotherapy and psychotropic medications. Insufficient documentation of prior adequate trials may result in denial.

List evidence-based psychotherapy type(s), dates, and duration within past 5 years
Provide psychotropic medication name, dose, start/end dates, and response for medications tried in past 5 years
If no psychotherapy or medication trials, provide clinical reason(s) why not appropriate or tolerated

Step Therapy

Step Therapy / Prior Treatments

TMS coverage requires evidence the member is treatment-resistant or intolerant to appropriate therapies. Provide documentation of lack of clinically significant response or intolerable side effects to psychopharmacologic agents and whether ECT was considered/declined when applicable.

Evidence of resistance or intolerance to psychopharmacologic agents in the current depressive episode
Documentation that member had an adequate trial of evidence-based psychotherapy without significant improvement within the past 5 years
If ECT was offered and declined, document that discussion and member decision

Denial Risk

Medical Contraindications — Denial Risk

TMS is contraindicated in members with certain implanted metal or magnetic-sensitive devices and some active neurological conditions. Presence of these contraindications may result in denial.

Contraindicated devices/items include cochlear implants, implanted cardiac defibrillators (ICD), pacemakers, vagus nerve stimulators, certain aneurysm clips/coils, metallic stents or staples within or near the treatment field
Active neurological contraindications: epilepsy or history of seizures, recent cerebrovascular disease, dementia, elevated intracranial pressure, recent severe/repetitive head trauma, primary or secondary CNS tumors
Also note acute or chronic psychotic symptoms, current substance abuse, pregnancy/nursing, or active suicidal plan — these factors affect eligibility

Level-of-Care: Outpatient TMS Eligibility

Outpatient TMS

Outpatient TMS requests require documentation of the following items for admission/prior authorization:

Level of care: Service is requested as Outpatient TMS and the request form (serving as the admission/prior authorization instrument) is completed and submitted.

Form fields capture required baseline data and serve as admission documentation.

Diagnosis and severity: Confirmed diagnosis of severe major depressive disorder (F32.2 or F33.2) and most recent validated depression scale score with date provided.

See diagnosis checkboxes and scale score field on form.

Prior treatments documented: Adequate trials of psychopharmacologic medications and evidence-based psychotherapy within the past 5 years are documented (or rationale for not attempting psychotherapy).within past 5 years

Medication tables and psychotherapy dates requested on form.

Psychiatrist authorization: Order written by a psychiatrist (MD or DO) who has examined the Member face-to-face and reviewed the record; supporting documentation submitted.

Form asks for attestation and supports attaching records.

Prior TMS history: History of prior TMS attempts (dates) and outcome documented if applicable; include prior outcome score(s) and dates when available.

Form contains fields for prior TMS outcome and PHQ-9 score/date.

Definitions and Target Diagnoses

Severe Major Depressive Disorder (MDD) — target ICD-10 codes

Primary target diagnoses (ICD-10)F32.2 — Major Depressive Disorder, Single Episode, Severe (Without Psychotic Features).

Recurrent severe MDD (ICD-10)F33.2 — Major Depressive Disorder, Recurrent Episode, Severe (Without Psychotic Features).

Use on request formForm lists F32.2 and F33.2 as the confirmed diagnosis options required for TMS requests.

Background

This request form is designed to support prior authorization of repetitive transcranial magnetic stimulation (TMS) for members with severe major depressive disorder (single or recurrent episode). It captures prior evidence-based psychotherapy dates and details, a 5-year psychotropic medication history, prior TMS attempts and outcomes, suicide risk, comorbid psychiatric and neurological conditions, and documentation that a psychiatrist examined the member face-to-face and provided the order.