CurrentBeacon-Health-OptionsPolicy N/A

Repetitive Transcranial Magnetic Stimulation (rTMS) Authorization Request Form — Coverage Criteria

Authorization form and documentation requirements for repetitive transcranial magnetic stimulation (rTMS) treatment requests submitted to Beacon/Beacon-Health-Options; applies to providers requesting prior authorization for outpatient rTMS services.

Policy Summary

PayerBeacon-Health-Options

PolicyrTMS Authorization Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed rTMS Authorization Request Form with the intake assessment attached to outpatientteam@carelon.com.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

requiredIntake assessment must be attached

5 yrsPsychotherapy and medication history timeframe

rating scaleRecent depression rating score requested

30 cmFerromagnetic material proximity threshold

Coverage Criteria

inv-01: Authorization criteria

Authorization requires completion of the form and attached documentation demonstrating ALL of the following:

Documented diagnosis and symptoms: Provide diagnosis code and description and intake assessment documenting associated symptoms and past TMS trials.

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Psychotherapy trial documented: Documentation of an adequate trial of evidence-based psychotherapy without significant improvement within the past 5 years, including type and dates.within 5 years

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Psychotropic medication history: List psychotropic medications from past 5 years with dose, dates of use, and clinical response; indicate whether meds were used during current depressive episode and whether improvement was inadequate at adequate dose/duration.

Policy Summary

PayerBeacon-Health-Options

PolicyrTMS Authorization Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed rTMS Authorization Request Form with the intake assessment attached to outpatientteam@carelon.com.

SourceLink

On This Page

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Safety screening: Document absence of or address contraindications (other implanted stimulators; ferromagnetic or magnetic-sensitive metals in head/neck within 11.81 inches (30 cm) of coil placement other than dental fillings; acute or chronic psychotic disorder; seizure disorder or history of seizures; substance abuse at time of treatments; severe dementia; non-adherence with previous depression treatments), and confirm whether first session will determine motor threshold and coil placement.

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Symptom severity measurement: Provide most recent score on a validated self-report depression rating scale, including the rating scale name, score, and date completed.

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Items captured on the rTMS Authorization Request Form that are flagged as present may include implanted stimulators, ferromagnetic or other magnetic‑sensitive metals implanted or embedded in the head or neck within 11.81 inches (30 cm) of the TMS coil (excluding dental fillings), acute or chronic psychotic disorder, seizure disorder or history of seizure disorder, active substance abuse at the time of treatments, severe dementia, and non‑adherence with previous depression treatments.

The form includes checklist items for conditions that would typically render rTMS unsuitable or require special consideration, including: presence of other implanted stimulators that are controlled by or that use electrical or magnetic signals (for example, vagus nerve stimulator leads in the carotid sheath), ferromagnetic or magnetic‑sensitive metals within 11.81 inches (30 cm) of coil placement, seizure disorder or history of seizures, psychotic disorders, active substance abuse, severe dementia, and documented non‑adherence with prior depression treatments.

Coding & Clinical Timeframes

Metal proximity threshold

Proximity distanceWithin 11.81 inches (30 cm) of TMS coil placement

Anatomic region specifiedHead or neck (excludes dental fillings)

PurposeUsed as a safety screening threshold to identify ferromagnetic or magnetic-sensitive materials that may contraindicate rTMS

Clinical history timeframe

Lookback period for psychotherapy and medicationsPast 5 years

Medication history details requiredMedication names, doses, start/end dates, and response within the past five years

Psychotherapy documentationType and dates of evidence-based psychotherapy within the past 5 years; if not done, reason must be provided

Provider Actions & Submission Requirements

Prior Authorization

Form submission and basic requirements

Submit the completed rTMS Authorization Request Form and attach the intake assessment documenting diagnosis (and associated symptoms), past TMS trials, psychotherapy, psychopharmacology, and psychometric measurement. Send securely via email to outpatientteam@carelon.com. Ensure treating and servicing clinician/facility, contact information, and member identifiers (name, DOB, policy #) are included on the form.

Secure submission: outpatientteam@carelon.com
Attach intake assessment documenting: diagnosis and symptoms; past TMS trials; psychotherapy history; psychotropic medication history; psychometric measurement scores
Include member identifiers: name, DOB, health plan, policy #, date/time of request
Include treating and servicing clinician/facility names, phone, NPI/TIN

Documentation Required

Prior psychotherapy and medication trials documentation

The form requires documentation of prior psychotherapy and detailed psychopharmacology trials. Document an adequate trial of evidence-based psychotherapy within the past 5 years (type and dates). List psychotropic medications used in the past five years with dose, start/end dates, and response (improved, inadequate response, adverse response, intolerability, non-adherence, other). Indicate whether medications were used during the current depressive episode and whether response was inadequate at adequate dose/duration or discontinued for side effects. If no medications were used, state whether they were contraindicated. List any augmenting agents.

Adequate trial of evidence-based psychotherapy within past 5 years: document type and dates; if not, provide reason
Psychotropic meds (past 5 years): name, dose, dates of use, response (improved / inadequate / adverse / intolerability / non-adherence / other)
Indicate if meds were used during current depressive episode and adequacy of dose/duration
List augmenting agents and reasons if meds were not used or discontinued

Denial Risk

Potential contraindications noted on form

The form includes screening for potential contraindications and other clinical exclusions. Review and document presence or absence of items listed on the form and attach relevant supporting details in the intake assessment.

Implanted stimulators controlled by or that use electrical or magnetic signals
Ferromagnetic or magnetic-sensitive metals implanted/embedded in head or neck within 30 cm (11.81 inches) of coil placement (other than dental fillings)
Vagus Nerve Stimulator leads in the carotid sheath
Acute or chronic psychotic disorder
Seizure disorder or history of seizure disorder
Substance abuse at time of treatments
Severe dementia
Non-adherence with previous depression treatments
None of the above (if applicable)

Background

This Authorization Request Form is used to request prior authorization for outpatient rTMS for depressive disorders. It collects the clinical history needed to assess suitability and safety for rTMS: diagnosis and intake assessment, prior treatment attempts (psychotherapy and psychotropic medications with names, doses, dates of use, and responses), presence of contraindications or risk factors, and whether the first session will include motor threshold determination and coil placement adjustment. The form also requests the most recent validated self‑report depression rating score to document baseline symptom severity.

Definitions

Ferromagnetic or magnetic-sensitive metals within 11.81 inches (30 cm) of TMS coil placement

Defined proximityFerromagnetic or magnetic-sensitive metals implanted or embedded in head or neck within 11.81 inches (30 cm) of TMS coil placement

Exception notedDental fillings are excluded from this checklist item

Use in screeningCheckbox on authorization form used to flag potential contraindication to rTMS

Other implanted stimulators controlled by or that use electrical or magnetic signals

Implanted stimulators specifiedOther implanted stimulators controlled by or that use electrical or magnetic signals

Example location includedVagus nerve stimulator leads in the carotid sheath are specifically queried on the form

RoleChecked as a contraindication or exclusionary condition on the authorization form

Level of Care Criteria

Treatment Modalities

inv-14: TMS

rTMS treatment suitability: Assess prior treatment adequacy (evidence-based psychotherapy and psychotropic medications), screen for contraindications (including implanted stimulators and ferromagnetic metals within 11.81 inches/30 cm of coil placement), document baseline depression rating, and ensure the first session includes determination of motor threshold and correct coil placement.

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