Prior Authorization Required

Prior approval is required.

• Prior approval required for TMS services (see Wellmark Authorization Table/InterQual for MDD criteria).
• Prior authorization is recommended for non-standard or investigational indications (e.g., accelerated, high-dose, MRI‑guided theta‑burst, deep TMS for non‑FDA indications).
• Prior authorization is recommended for newer or nonconventional TMS protocols (accelerated, high‑dose, Stanford Neuromodulation Therapy, MRI‑guided theta burst) to document rationale, device/modal parameters, and supporting evidence.
• Prior authorization requests should specify the TMS modality, device, stimulation parameters, proposed schedule (frequency, pulses per session, total sessions), and treatment target to allow clinical review.

Documentation: Baseline Severity and Prior Treatment

Baseline severity and prior treatment must be documented as used in clinical trials and InterQual guidance.

• Document baseline symptom severity with a validated rating scale (e.g., MADRS, HAM‑D, YBOCS for OCD) and record baseline scores.
• Document prior treatment history including adequate trials of pharmacotherapy, psychotherapy, ECT (when relevant), and reasons for failure/intolerance or contraindication.
• Record patient‑reported outcomes and trial measures used in studies (daily headache diaries for migraine trials; motor threshold and cortical mapping for TMS sessions).

Required Clinical and Trial-Based Documentation

Clinical documentation supporting a TMS authorization should include indication, prior therapies tried and outcomes, rationale for TMS, and a detailed treatment plan.

• Indication and diagnosis with relevant ICD code and supporting history.
• Prior conservative therapy attempts (medications, psychotherapy, device‑specific prior treatments) with dates and outcomes.
• Rationale for chosen TMS modality and why standard therapies were inadequate, intolerable, or contraindicated.
• Treatment plan: target brain region, frequency (Hz or iTBS), intensity (% resting motor threshold), pulses per session, sessions per day/week, total planned sessions, and taper schedule if applicable.
• Provider and device details: FDA‑cleared device model (when applicable) and clinician qualifications/training.
• Baseline and planned outcome measures (e.g., MADRS, response/remission thresholds, YBOCS), and schedule for assessment during and after treatment.

Billing and Code Reporting for Authorization

Use appropriate CPT/HCPCS/ICD codes when requesting authorization and when billing; missing or incorrect codes may lead to denial.

• Report relevant CPT codes for TMS: e.g., 90867 (initial mapping and delivery), 90868/90869 equivalents for subsequent sessions as applicable; report specific Category III codes for accelerated fcMRI‑guided theta‑burst (0889T–0892T) when used.
• Include HCPCS, revenue, and ICD‑10 diagnosis codes consistent with the indication and site of service.
• Codes must match the modality billed (conventional rTMS vs deep TMS vs accelerated/experimental protocols) — mismatched or omitted codes increase coding‑related denial risk.

Combination TMS + Esketamine Investigational

Combination therapy with simultaneous TMS plus esketamine is not covered and is considered investigational.

• Concurrent or simultaneous administration of TMS with esketamine is investigational and lacks sufficient evidence for safety, optimal regimen, or standard‑of‑care recognition.
• Authorization requests for combined TMS + esketamine should indicate investigational status and will generally be denied.

Regulatory/Labeling Limitations

FDA labeling limitations and device/indication notes should be acknowledged in requests.

• Confirm FDA‑cleared indications for the device being used (e.g., MDD, OCD, certain migraine indications) and note age/label limits (e.g., NeuroStar approval for adolescents 15–21 as adjunct for MDD per March 2024).
• FDA labeling warns devices have not been demonstrated effective/safe for cluster headache, chronic migraine, or migraine during aura phase in some device labels.
• Specify whether the device is FDA‑cleared for the requested indication; non‑cleared indications are considered investigational.

Auditory Hallucinations — Research Use Only

Use of TMS for auditory hallucinations should be considered research‑only per NICE guidance and may be denied outside of clinical trials.

• NICE (2020) concluded evidence is inadequate for efficacy of TMS for auditory hallucinations and recommended use only in research settings.
• Authorization requests for auditory hallucinations should reference the research‑only status and include trial enrollment information if applicable.

Reference-Only Material and Cross-References

Some sections of the source are reference‑only and do not establish utilization, authorization, or specific denial rules; reviewers should use this policy together with Wellmark Authorization Table and InterQual criteria.

• InterQual criteria are referenced for MDD — follow Wellmark Authorization Table for operational prior authorization rules.
• Where the policy is silent on prior authorization specifics for certain items, follow payer's authorization table/process ("Prior authorization: not specified in this section").
• Reference lists and background evidence (systematic reviews, ongoing trials) are informational and do not by themselves authorize coverage.

Trial-Based Documentation Expectations

Trial documentation expectations mirror published studies and should include validated outcome measures and session‑level records.

• Record motor threshold determination and cortical mapping per initial session.
• Document each treatment day: device used, settings (intensity, frequency, pulses), site targeted, session duration, and any adverse events.
• Use validated scales for outcomes and specify response/remission definitions used in trials (e.g., MADRS response = ≥50% reduction; remission = MADRS ≤10; OCD response = ≥30% reduction in YBOCS).

Ongoing and Unpublished Trials

Ongoing or unpublished clinical trials may change evidence and coverage; cite clinicaltrials.gov identifiers when relevant.

• Include references to ongoing trials if the request relies on emerging evidence; list NCT numbers if available.
• Acknowledgement that newer protocols lack long‑term durability and larger trials are pending (e.g., SNT trials) should be included in rationale for experimental protocols.

Step Therapy and Comparators

No step therapy rules are specified in this section; use Wellmark Authorization Table and InterQual for step requirements and sequencing relative to other therapies.

• Where step therapy or sequencing is relevant (e.g., failure of adequate pharmacologic trials before rTMS for MDD), follow the payer's authorization criteria rather than this narrative section.
• VA/DoD guidance suggests rTMS as an adjunctive option after pharmacologic trial(s) in bipolar depression but is a weak recommendation with very low confidence; document pharmacologic treatment attempts when applicable.