CurrentBlue Cross Blue Shield - MainePolicy N/A

Transcranial Magnetic Stimulation (TMS) Request — Coverage Criteria

Form and clinical requirements governing authorization requests for transcranial magnetic stimulation (TMS) for treatment of major depressive disorder and other indications for Anthem/Blue Cross Blue Shield plans (Maine referenced). Affects ordering providers submitting TMS authorization requests.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyTranscranial Magnetic Stimulation (TMS) Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed TMS request form including demographics, provider NPI, depression rating scores, detailed medication trial history, requested start date, and number of sessions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30standard acute TMS course length

>=18min age

TBS NMNTBS status

2+required med trials

Coverage Criteria for TMS

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyTranscranial Magnetic Stimulation (TMS) Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed TMS request form including demographics, provider NPI, depression rating scores, detailed medication trial history, requested start date, and number of sessions.

SourceLink

On This Page

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Age: Individual is 18 years or older.>=18 years

Diagnosis: Confirmed diagnosis of treatment-resistant major depressive disorder (single or recurrent episode).

Prior pharmacotherapy: Inadequate response to pharmacotherapy despite adequate duration and dosage with documented adherence and trials from 2 or more classes of medications; OR inability to tolerate pharmacotherapy evidenced by 2 trials with documented side effects.>=2 medication classes OR 2 intolerance trials

Device and parameters: TMS will be administered by a U.S. FDA-approved device for the treatment of MDD using manufacturer-specified stimulation parameters.

If device specified on form, document device model.

Course limits: Standard acute treatment does not exceed 5 days/week for 6 weeks (total 30 sessions) followed by a 3-week taper (3 sessions week 1, 2 sessions week 2, 1 session week 3).<=30 sessions acute + 3-week taper

Safety screening: No implanted magnetic-sensitive medical device located ≤30 cm from the TMS coil; no current substance use that significantly lowers seizure threshold; no active seizure disorder (exceptions: isolated febrile seizures in infancy without recurrence or ECT-induced seizures) and no acute or chronic psychotic symptoms in the current depressive episode.

Dental amalgam fillings acceptable.

Prior to TMS, screen for implanted magnetic‑sensitive medical devices. TMS is not appropriate when an implanted magnetic‑sensitive device is located ≤30 cm from the TMS coil (examples listed on the form include cochlear implants, implanted cardioverter defibrillators, pacemakers, vagus nerve stimulators, deep brain stimulators, metal aneurysm clips/coils/staples/stents, and other implanted devices). Dental amalgam fillings are explicitly acceptable.

Assess current substance use because active use of substances that may significantly lower seizure threshold (for example, alcohol or stimulants) is listed as a contraindication and may render TMS inappropriate. The form requires documentation that the individual has no current use of substances that may significantly lower seizure threshold.

Coding and Visit Limits

Covered CPT CodesCPTCovered

90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management
90868	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management; per session
90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; motor threshold re-determination with delivery and management; subsequent

inv-07: Standard acute course — Up to 30 sessions over 6 weeks plus a 3-week taper (3 sessions week 1, 2 sessions week 2, 1 session week 3)

Acute course lengthStandard acute course: up to 5 days/week for 6 weeks (total of 30 sessions)

Taper schedule3-week taper following acute course: 3 sessions in week 1, 2 sessions in week 2, 1 session in week 3

Maximum sessionsAcute phase + taper not to exceed 30 sessions in the 6-week acute period; taper sessions occur after the 6-week period

inv-18: TMS sessions — 30 acute sessions plus specified 3-week taper

Acute TMS sessions30 acute sessions delivered over 6 weeks (up to 5 days/week)

Post-acute taper3-week taper after the 6-week acute course: 3 sessions week 1, 2 sessions week 2, 1 session week 3

Device requirementAdministered by a U.S. FDA–approved device using manufacturer-specified stimulation parameters

Provider Actions and Documentation Requirements

Prior Authorization

Prior authorization required

Prior authorization required — Prior authorization is required for Transcranial Magnetic Stimulation (TMS). Submit a completed TMS request form (fax: 866-834-7469) that includes member demographics, provider NPI, device (if applicable), and clinical details. Include the prior authorization number for retreatment requests when available.

Fax completed TMS request form to 866-834-7469
Include prior authorization number for retreatment if available
Provide member demographics, provider NPI, and device information

Step Therapy

Pharmacotherapy requirement

Pharmacotherapy requirement — Document inadequate response to pharmacotherapy for the current depressive episode. Records must show trials from two or more medication classes with adequate dose, duration, and documented adherence, or documented intolerance (at least two trials with side effects). Include dates, maximum doses, durations, outcomes, side effects, and adherence information for each trial.

Document trials from ≥2 medication classes with adequate dose, duration, and adherence
If unable to tolerate medications, document ≥2 trials with side effects and intolerance details
Include date of trial, maximum dose, duration, outcome, side-effects, and adherence for each trial

Documentation Required

Required documentation

Required documentation — Submit the completed Transcranial Magnetic Stimulation Request form including member demographics, provider NPI, requested start date, number of sessions/units, device (if applicable), and standardized depression rating scales or copy of psychiatric evaluation within 3 months. Ensure the form is signed by the requesting clinician.

Completed TMS request form (signed) with member demographics and provider NPI
Requested start date and number of sessions/units
Specify FDA-approved device if used and stimulation parameters per manufacturer
Attach standardized depression rating scales or full psychiatric evaluation within 3 months

Denial Risk

Theta burst stimulation (TBS) not covered

TBS not covered — Theta burst stimulation (TBS) is considered not medically necessary for all indications and requests for TBS can be denied.

Theta burst stimulation (TBS) is not medically necessary for all indications

Background

Transcranial magnetic stimulation (TMS) is requested primarily for treatment‑resistant major depressive disorder (MDD). The form specifies that the standard acute treatment course is up to 5 days per week for 6 weeks (total of 30 sessions) followed by a 3‑week taper (3 sessions in week 1 of taper, 2 sessions in week 2, and 1 session in week 3). Screening for seizure history, implanted magnetic‑sensitive devices, psychotic symptoms in the current episode, and substance use that lowers seizure threshold is required before treatment.

Definitions

inv-13: Retreatment defined — previous response ≥50% reduction on standardized scale and clinically meaningful worsening

Definition of retreatmentPrevious response to TMS demonstrated by ≥50% reduction on a standardized rating scale AND recurrence of depression with clinically meaningful worsening relative to best TMS response

DocumentationAuthorization number for prior treatment requested if available

Eligibility implicationRetreatment requests must show prior meaningful response and subsequent clinical worsening to support coverage

inv-14: Maintenance treatment — continues after remission (virtual absence of depressive symptoms for at least 3 weeks).

Maintenance definitionMaintenance treatment: continues after remission (remission = virtual absence of depressive symptoms for at least 3 weeks)

PurposeUsed to sustain remission and may end with relapse or recovery

Form requirementForm asks whether request is for maintenance and documents the definition

inv-15: Continuation treatment — therapy after the acute index course, lasts up to 6 months to prevent worsening.

Continuation definitionContinuation treatment: begins after the acute index course and lasts up to 6 months to prevent worsening

TimingInitiated following completion of the acute 6-week course (and taper as applicable)

Coverage noteForm requests whether the treatment is for continuation and documents definitions to support coverage

OpenPayer

Transcranial Magnetic Stimulation (TMS) Request — Coverage Criteria

Coverage Criteria for TMS

Coding and Visit Limits

Provider Actions and Documentation Requirements

Background

Definitions

Level of Care Criteria

Treatment Modalities

Visit Limits