CurrentBlue Cross Blue Shield - MainePolicy N/A

Transcranial Magnetic Stimulation (TMS) testing / authorization form

This document is a TMS testing request/authorization form used by Anthem/Blue Cross and Blue Shield for requesting TMS for adults with major depressive disorder and related conditions; it governs information and clinical criteria required on prior authorization requests for participating providers in the referenced Indiana products.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyTranscranial Magnetic Stimulation (TMS) testing / authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests electronically via Availity (or fax if unable) including the completed TMS request form with required clinical details and confirmation of FDA/manufacturer stimulation parameter conformity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30+ taperTreatment course

>=4Required prior trials

>=2Different agent classes

50%+Prior TMS response threshold

Adults

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Coverage Criteria for TMS

Initial TMS therapy coverage criteria

Covered when ALL of the following are met:

Population and diagnosis: Individual is an adult with a confirmed diagnosis of severe major depressive disorder (single or recurrent episode).

Prior treatment failure or intolerance: Individual has failed to significantly respond to prior treatment or is unable to tolerate psychopharmacologic agents as evidenced by four trials of psychopharmacologic agents in the current depressive episode; treatment trials include at least two different agent classes at or above the minimum effective dose and duration, and include at least two evidence-based augmentation therapies when indicated.four trials

Alternatively documented intolerance to agents may apply.

Prior response to TMS: If individual has history of response to TMS in a previous depressive episode, there is greater than 50% improvement documented on a standard depression rating scale.>50% improvement

Specify rating scale used (e.g., BDI, GDS, HAMD, IDS-SR, MADRS, PHQ-9, QIDS)

Psychotherapy: Individual has had a trial of evidence-based psychotherapy known to be effective for MDD; psychotherapy trial had adequate frequency and duration and results were documented with standardized rating scales when available.

Specify psychotherapy model and results.

Device and treatment parameters: TMS will be administered using an FDA-approved device for the treatment of MDD and in accordance with the manufacturer's user manual; proposed treatment should be consistent with FDA/manufacturer stimulation parameters (five days per week for six weeks, total 30 sessions, followed by a three-week taper of 3, 2, and 1 sessions) unless provider documents rationale.FDA parameters

Specify device model if indicated.

ECT consideration: Individual is currently receiving ECT and TMS is considered a less invasive treatment option, or individual is a candidate for and has declined ECT and TMS is considered a less invasive treatment option.

Individuals with acute or chronic psychotic symptoms or disorders—for example schizophrenia, schizophreniform disorder, or schizoaffective disorder—during the current depressive episode must be disclosed and are noted as potential contraindications to TMS. Additionally, individuals with certain neurological conditions (including epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary/secondary CNS tumors) or with an implanted magnetic‑sensitive medical device located ≤30 cm from the TMS coil should be identified on the request form; these conditions may preclude coverage or require further clinical justification and safety review.

Requests must state whether the proposed TMS course is consistent with the FDA and manufacturer stimulation parameters. The FDA/manufacturer‑specified protocol is five days per week for six weeks (total of 30 sessions), followed by a specified three‑week taper of 3 sessions in week 1, 2 sessions in week 2, and 1 session in week 3. Requests that propose a treatment course not consistent with these parameters must include a clinical rationale; lack of conformity with these parameters may place the request at risk for denial.

Stimulation Parameters & Coding Notes

FDA/manufacturer stimulation parameters — initial course and taper

Stimulation scheduleFive days per week for six weeks (total 30 sessions)

Taper scheduleThree-week taper: 3 sessions in week 1, 2 sessions in week 2, 1 session in week 3

Total sessions including taper30 initial sessions plus 6 taper sessions (as specified by 3+2+1)

Device requirementAdministered using an FDA-approved device per manufacturer user manual

Documentation promptIndicate whether proposed treatment is consistent with FDA/manufacturer parameters on request form

Submission, Documentation & Authorization Actions for Providers

Prior Authorization

Prior Authorization Required — Submission and Authorization Request

Submit prior authorization requests electronically via Availity (https://Availity.com) whenever possible. If Availity submission is not feasible, fax the completed TMS request form to the appropriate behavioral health fax number for the product line (see provider fax list). Include the completed TMS Treatment Request Form with all required sections filled. Requests should be submitted prior to the scheduled start of treatment.

Preferred submission: https://Availity.com
If unable to use Availity, fax completed form to appropriate behavioral health fax number (see TMS form/fax list)
Attach the completed Transcranial Magnetic Stimulation (TMS) Treatment Request Form

Documentation Required

Documentation and Treatment-Parameter Alignment

Ensure documentation demonstrates that the proposed treatment aligns with FDA-approved stimulation parameters and the manufacturer's user manual. If the requested course deviates from FDA/manufacturer parameters, provide a clear clinical rationale and supporting documentation. For maintenance TMS requests, include date of most recent treatment and rationale for maintenance therapy.

Background

This form is used to request TMS for adults with a confirmed diagnosis of severe major depressive disorder (single or recurrent episode). It collects clinical information needed to determine medical necessity, including prior medication and psychotherapy trials, prior response to TMS if any, any contraindicating neurological conditions or implanted magnetic‑sensitive devices within ≤30 cm of the coil, and confirmation that the proposed device and treatment parameters follow the manufacturer's user manual and FDA‑specified stimulation schedule.

Definitions

Augmentation therapy definition

DefinitionA drug regimen consisting of one or more drugs added to an antidepressant to increase efficacy

ExampleAdding pindolol to fluoxetine

Use caseUsed when initial antidepressant therapy has been insufficient; documented augmentation trials are required when indicated

DocumentationRecord specific augmentation agents, dose, duration, and outcome in the medication history

Transcranial Magnetic Stimulation (TMS)

TMS

TMS device and protocol: Use of an FDA-approved device and adherence to manufacturer user manual and FDA-specified stimulation parameters (five days per week for six weeks = 30 sessions, followed by a three-week taper: 3 sessions week 1, 2 sessions week 2, 1 session week 3) is expected.30 sessions + 3-week taper

Specify device if indicated.

Treatment Session Limits and Schedule

TMS treatment — initial course and 3-week taper

Initial session count30 sessions delivered over six weeks (five sessions per week)

Taper patternThree-week taper delivered as 3 sessions the first week, 2 sessions the second week, and 1 session the third week

Visit limits summary30 initial sessions plus the 3-week taper (3,2,1)

Alignment requirementProposed treatment should conform to FDA/manufacturer stimulation parameters unless rationale documented