CurrentBeacon-Health-OptionsPolicy N/A

Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form / Coverage Criteria

A provider-facing request form used to document clinical information and authorization prerequisites for rTMS for members with severe major depressive disorder; affects psychiatrists and treating providers submitting prior authorization to Beacon Health Options.

Policy Summary

PayerBeacon-Health-Options

PolicyRepetitive Transcranial Magnetic Stimulation (rTMS) Request Form / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the rTMS request form with clinical details, documented psychiatrist order, 5-year medication and psychotherapy history, and recent validated depression scale score to obtain prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 codesDiagnosis options

5 yearsHistory lookback

PHQ-9/MADRS/BDI...Validated scales

90867-90869Procedure codes

Coverage Criteria for rTMS

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Initial rTMS coverage criteria

Covered when ALL of the following are met

Primary diagnosis: Confirmed diagnosis of severe major depressive disorder (single or recurrent) documented as F32.2 or F33.2

select diagnosis on form

Treatment resistance or intolerance: Member has had resistance to or inability to tolerate psychopharmacologic agents in the current depressive episode, or has declined ECT and TMS is considered a less invasive treatment option

medication trial history for past 5 years documented on form

Prescribing clinician and evaluation: Order written by a psychiatrist (MD or DO) who has examined the member face-to-face and reviewed the record; documentation must be submitted

checkbox and signature/notes on form

Psychotherapy trial: Adequate trial of evidence-based psychotherapy within the past 5 years without significant improvement, or explanation provided if not tried5 years

dates and type of psychotherapy requested on form

Baseline severity: Most recent validated self-report depression scale score provided (PHQ-9, MADRS, BDI, HAM-D, GDS, etc.)

scale name, score, and date fields on form

The following conditions and patient characteristics are listed as exclusions or amplified risk factors to consider when evaluating rTMS candidacy. Members with an implanted magnet-sensitive device or other implanted metal items — including but not limited to a cochlear implant, implanted cardiac defibrillator (ICD), pacemaker, vagus nerve stimulator, metal aneurysm clips/coils, surgical staples, or stents — located at or expected to be within 30 cm of the TMS magnetic coil should be identified and excluded unless cleared by appropriate specialty consultation. Neurological disorders that increase procedural risk are also noted: epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary/secondary central nervous system tumors. These factors are captured on the request form and should be addressed before authorizing outpatient rTMS.

rTMS is considered not medically necessary when any of the listed contraindications are present. These contraindications on the form include presence of implanted magnet-sensitive devices or nearby implanted metal; a seizure disorder or history of seizures; active or acute psychotic symptoms; current substance abuse at the time of treatment; pregnancy or nursing; or a current suicide plan or recent suicide attempt. If any of these conditions are checked on the form, the request should be denied unless compelling, documented justification and appropriate specialist clearance are provided.

Diagnostic and Procedure Codes

Covered ICD-10 Diagnoses (form options)ICD-10

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

Procedure CPT Codes for rTMSCPTCovered

90867	initial, including cortical mapping, motor threshold determination, and delivery management
90868	subsequent delivery and management per session
90869	subsequent motor threshold redetermination with delivery and management

Clinical history lookback

Clinical history lookback periodPast 5 years — psychotherapy and psychotropic medication history must be documented on the form (dates, medications, responses)

Psychotherapy dates requiredDates of evidence-based psychotherapy trial within the past 5 years must be provided on the form

Medication history detailsPsychotropic medications taken within the past five years: name, dose, start/end dates, and treatment response must be listed

Prior Authorization & Documentation Requirements

Prior Authorization

Prior authorization submission — request form and CPT codes required

Complete and submit the rTMS request form (prior authorization) with the clinical details and selected CPT code(s) for the requested treatment (90867, 90868, or 90869) and requested units/dates listed on the form.

Form must include CPT code(s) 90867, 90868, or 90869 and units/start/end dates.

Step Therapy

Step history requirements — medication and psychotherapy trials (5-year lookback)

Document prior trials of psychopharmacologic agents and evidence-based psychotherapy within the past 5 years on the request form, including dates, responses, and reasons for discontinuation or intolerance when applicable.

List psychotropic medications taken within the past five years with dose, start/end dates, and response (improved, inadequate response, adverse response, intolerability, non-adherence, other).
Provide dates and type of evidence-based psychotherapy within the past 5 years or explain why psychotherapy was not tried.

Documentation Required

Required documentation — psychiatrist exam and record review

Submit documentation that the order for TMS was written by a psychiatrist (MD or DO) who examined the member face-to-face and reviewed the record; include the psychiatrist's evaluation and supporting records with the request form.

Checkbox on form confirms psychiatrist (MD or DO) has examined member face-to-face and reviewed the record; attach supporting documentation.
Include medication history and psychotherapy dates/outcomes as part of the supporting documentation.

Denial Risk

Contraindications / denial triggers — implanted devices and neurological conditions

Do not submit authorization requests for members with any listed contraindications; presence of implanted magnet-sensitive devices or specified neurological conditions may trigger denial.

Contraindications include implanted magnet-sensitive devices or implanted metal items (e.g., cochlear implant, ICD, pacemaker, vagus nerve stimulator, metal aneurysm clips/coils, staples, stents) located ≤30 cm from the TMS magnetic coil.
Also check for acute or chronic psychotic symptoms, seizure disorder or history of seizures, cerebrovascular disease, dementia, increased intracranial pressure, history of severe/repetitive head trauma, CNS tumors, substance abuse at time of treatment, pregnancy/nursing, or current suicide plan/attempt.

Background

Repetitive Transcranial Magnetic Stimulation (rTMS) is requested for members with confirmed severe major depressive disorder (single or recurrent episode) who have had an inadequate response or intolerance to pharmacologic treatment, or who have declined or are considered alternatives to electroconvulsive therapy. The request form documents prior TMS response, captures psychotherapy and medication history within the past 5 years, and records the most recent validated depression scale score (e.g., PHQ-9, MADRS, BDI, HAM-D, GDS) to establish baseline severity prior to authorization.

Level of Care

Outpatient — level of care criteria

Outpatient rTMS admission: Member meets diagnostic, treatment-resistance/intolerance, clinician order, psychotherapy and medication history, and baseline severity documentation as captured on the request form

Form used to support outpatient rTMS authorization

Continued treatment monitoring: Documentation of prior TMS response (if previous TMS) and ongoing response measures (e.g., PHQ-9) should be provided for continuation/ongoing authorization

form requests prior TMS dates and outcomes