CurrentBlue Cross Blue Shield - MassachusettsPolicy BCBSA Reference Number: 2.01.50

Repetitive transcranial magnetic stimulation (rTMS/dTMS) for major depressive disorder

Defines medical necessity, investigational indications, prior authorization, coding, and contraindications for rTMS/dTMS using FDA-cleared devices for Commercial and Medicare members of Blue Cross Blue Shield Massachusetts.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyRepetitive transcranial magnetic stimulation (rTMS/dTMS) for major depressive disorder

Policy CodePolicy BCBSA Reference Number: 2.01.50

Change TypeClarification / Annual review

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests using Authorization Manager with the Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form and provide documentation of diagnosis, prior medication and psychotherapy trials, intolerance, and prior rTMS response when applicable.

POLICY UPDATE CHANGES

Prior authorization is required on codes 90867, 90868, 90869.

Annual policy review with updates to description, summary, and references; policy statements unchanged.

Policy clarified to include prior authorization requests using Authorization Manager.

1Covered Indications (major depressive disorder when criteria met)

MultipleInvestigational / Not covered Indications

3Contraindication categories

CPT/HCPCS codes called out

Coverage Summary

Scope: Defines medical necessity, investigational indications, prior authorization, coding, and contraindications for rTMS/dTMS using FDA-cleared devices for Commercial and Medicare members of Blue Cross Blue Shield Massachusetts. Coverage stance: rTMS/dTMS is covered for treatment-resistant major depressive disorder (TRD) when specific medical necessity criteria are met and is investigational for other indications and for maintenance therapy. Context: Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation technique used primarily for TRD, with modality variations such as deep TMS and theta-burst stimulation.

Surface thresholds and operational facts

policy_numberBCBSA Reference Number: 2.01.50

subjectRepetitive transcranial magnetic stimulation (rTMS/dTMS) for major depressive disorder

treatment course frequency/lengthUp to 5 days/week for 6 weeks (total 30 sessions), followed by a 3-week taper: 3 sessions in week 1, 2 sessions in week 2, 1 session in week 3

prior rTMS response interval (threshold)History of response to rTMS in prior depressive episode required — at least 3 months since the prior episode

prior authorization requirement (codes)Prior authorization required for outpatient services; policy history clarifies prior authorization is required on codes 90867, 90868, 90869

last_review2024-12

Medical Necessity and Operational Criteria

Commercial Members - Medical Necessity for rTMS/dTMS for Major Depressive Disorder

rTMS or dTMS may be considered MEDICALLY NECESSARY when ALL of the following are met:

ALL of the following

Confirmed diagnosis of severe major depressive disorder (single or recurrent) documented by standardized rating scales that reliably measure depressive symptoms
Treatment history requirement
- Failure of 4 trials of psychopharmacologic agents including 2 different agent classes and 2 augmentation trials
- Inability to tolerate a therapeutic dose of medications as evidenced by 4 trials of psychopharmacologic agents with distinct side effects

Not Medically Necessary / Investigational

Commercial Members - Not Medically Necessary / Investigational

rTMS/dTMS is considered investigational or not medically necessary when ANY of the following apply:

ANY of the following

rTMS/dTMS for major depressive disorder that does not meet the criteria listed in the medical necessity section
Continued treatment with rTMS/dTMS as maintenance therapy
rTMS/dTMS as a treatment for all other psychiatric/neurologic disorders (including but not limited to bipolar disorder, schizophrenia, obsessive-compulsive disorder, migraine headaches, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, substance use disorders, epilepsy, chronic pain, fibromyalgia, Parkinson disease, stroke recovery, amyotrophic lateral sclerosis)

Contraindications to rTMS

Coding

Covered CPT Codes (must meet medical necessity criteria)CPTCovered

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; subsequent motor threshold re-determination with delivery and management
0889T	Personalized target development for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation; including data preparation and transmission, generation of the target; motor threshold-starting location, neuronavigation files and target report
0890T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation; initial treatment day (report once on the first day of course)
0891T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation; subsequent treatment day
0892T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation; subsequent motor threshold redetermination with delivery and management, per treatment day

Coding informational noticemixed

No codes listed

Provider Actions and Billing Rules

Prior Authorization

Preauthorization required for outpatient and inpatient services

Precertification/preauthorization is required for inpatient services; prior authorization is also required for outpatient services for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity. Providers must submit the Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form and use Authorization Manager for initial requests.

Affected CPT codes: 90867, 90868, 90869, 0889T, 0890T, 0891T, 0892T
Use the Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form for outpatient prior authorization
Submit initial requests via Authorization Manager

Documentation Required

Clinical documentation to support medical necessity

Documentation must demonstrate the clinical rationale and medical necessity for rTMS/dTMS per policy criteria.

Background, Evidence Summary, and Definitions

Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation technique in which a coil placed over the scalp generates a magnetic field that induces electrical stimulation of the cortex. Repetitive TMS (rTMS) delivers repeated electromagnetic pulses, typically over the dorsolateral prefrontal cortex, and does not require general anesthesia or induce convulsions as with ECT.

Modalities include deep TMS (dTMS), which uses an H-coil helmet to stimulate broader and deeper brain regions, and theta-burst stimulation, a patterned form delivered at lower intensities and shorter intervals than conventional rTMS. Other parameter variations differ in frequency, intensity, pattern, and target site.

Evidence: For treatment-resistant depression (TRD), multiple sham-controlled randomized controlled trials and meta-analyses show improved response and remission rates for conventional TMS and theta-burst versus sham, with benefits generally in the short term and limited durability; the average effect is smaller than ECT though some higher-frequency protocols showed clinically meaningful improvements. For migraine, OCD, and many other psychiatric and neurologic disorders, trials are heterogeneous, often small, and of limited quality, and the evidence is insufficient to establish durable clinical benefit for these other indications.

Evidence	Summary
RCT / Meta-analyses
Multiple sham-controlled RCTs and meta-analyses show improved response/remission rates for conventional TMS and theta-burst vs sham in TRD; effect smaller than ECT overall
OCD deep TMS trial
Prospective RCT (n~99) showed improvement on YBOCS at 6 weeks in modified ITT; additional trials needed
Migraine
Systematic review and single RCT had limitations (high dropout, post hoc analysis); evidence insufficient

Glossary:

rTMS: Repetitive transcranial magnetic stimulation — repeated electromagnetic pulses to modulate neural activity, typically applied over the dorsolateral prefrontal cortex.

dTMS / deep TMS: Deep transcranial magnetic stimulation — employs an H-coil helmet design to stimulate broader surface areas and deeper brain structures compared with conventional TMS.

Theta-burst stimulation: A patterned form of TMS delivering bursts at lower intensities and shorter intervals than conventional rTMS.

Medicare Local Coverage Determination

Name	Number	Type	Effective Date
Transcranial Magnetic Stimulation
L33398
LCD

Revision History

7/2024material_clarificationLatest

Policy clarified: Prior authorization is required on codes 90867, 90868, 90869.

12/2023administrative_update

Annual policy review: Description, summary, and references updated; policy statements unchanged.

9/2023administrative_update

Policy clarified to include prior authorization requests using Authorization Manager; providers must use Authorization Manager to submit initial authorization requests and enter appropriate provider and facility NPIs.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyRepetitive transcranial magnetic stimulation (rTMS/dTMS) for major depressive disorder

Policy CodePolicy BCBSA Reference Number: 2.01.50

Change TypeClarification / Annual review

Effective Date

Next Review Date

On This Page

Is a candidate for electroconvulsive therapy and ECT would not be clinically superior to rTMS (rTMS should NOT be used in cases with psychosis, acute suicidal risk, catatonia, or life‑threatening inanition)

History of response to rTMS in a previous depressive episode (at least 3 months since the prior episode)

Failure of a trial of a psychotherapy known to be effective in the treatment of major depressive disorder of an adequate frequency and duration, without significant improvement in depressive symptoms, as documented by standardized rating scales that reliably measure depressive symptoms

Treatment Course Parameters (Operational Guidance)

Recommended maximum course and device requirement (operational guidance):

ALL of the following

Treatment course frequency/length: A treatment course should not exceed 5 days a week for 6 weeks (total of 30 sessions)Up to 5 days/week for 6 weeks (30 sessions)
Taper schedule: Follow with a 3-week taper: 3 TMS treatments in week 1, 2 TMS treatments in week 2, and 1 TMS treatment in week 33-week taper (3, then 2, then 1 session)
Device requirement: Treatment should be performed using a U.S. Food and Drug Administration cleared device in appropriately selected patientsFDA-cleared device

rTMS is contraindicated when ANY of the following are present:

ANY of the following

Presence of acute or chronic psychotic symptoms or disorders (e.g., schizophrenia, schizophreniform or schizoaffective disorder) in the current depressive episode
Seizure disorder or any history of seizure with increased risk of future seizure
Neurologic conditions that include epilepsy, cerebrovascular disease, dementia, increased secondary tumors in the central nervous system
Presence of an implanted magnetic-sensitive medical device located within 30 centimeters from the TMS magnetic coil or other implanted items including but not limited to a cochlear implant, implanted cardioverter defibrillator, pacemakers, vagus nerve stimulator or metal aneurysm clips or coils, staples, or stentswithin 30 cm of coil

Standardized rating scales documenting diagnosis and symptom severity
Details of prior medication trials: agents tried, doses, durations, classes, and any augmentation trials (failure of 4 trials including 2 different classes and 2 augmentation trials when applicable)
Psychotherapy trial details: type, frequency, duration, and lack of significant improvement
Evidence of intolerance to medications, if applicable
Documentation of prior response to rTMS when claimed (including timing; prior episode must be at least 3 months earlier)

Billing Rule

Report 0890T once per course

Follow coding guidance for accelerated theta-burst stimulation: report the initial treatment day code once per course and do not report it with the listed imaging code.

Report CPT 0890T once on the first day of the course of accelerated theta-burst stimulation
Do not report 0890T in conjunction with 77022
Codes referenced: 0890T, 77022

Prior Authorization

Authorization Manager submission specifics

When submitting initial authorization requests via Authorization Manager, enter provider and facility identifiers exactly as required to ensure accurate processing.

Enter the appropriate surgeon's NPI or provider ID as the servicing provider (not the billing group)
Enter the facility's NPI or provider ID for the service location

Treatment-resistant depression (TRD): Major depressive disorder not adequately responding to standard pharmacologic and psychotherapeutic treatments as specified in the policy criteria (e.g., failure of specified medication and psychotherapy trials).