Transcranial Magnetic Stimulation (TMS) request form and coverage criteria
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This document is a payer request/authorization form and associated coverage guidance for TMS treatment requests submitted to Blue Cross Blue Shield - Nevada; it governs pre-authorization submission content and clinical screening for members seeking TMS for depressive and other neuropsychiatric conditions.
No material clinical or coverage changes in this revision.
Coverage Criteria for TMS
Initial TMS for MDD
Covered when ALL of the following are met for Depressive Disorder requests:
from form checkboxes
documented on form
form checkbox
form specifies schedule
checkbox exclusions on form
form lists neurological exclusions
The request form and coverage guidance include specific caveats and contraindications to ensure safe candidate selection for transcranial magnetic stimulation (TMS). The form identifies that individuals with a history of seizure disorder or prior seizure (except ECT-induced or isolated febrile seizures in infancy without recurrence), active acute or chronic psychotic symptoms or disorders during the current depressive episode, or certain neurological conditions (for example epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, severe/repetitive head trauma, or CNS tumors) are excluded from routine TMS coverage unless otherwise addressed. The form also requires screening for current use of substances that may significantly lower seizure threshold and documents implanted magnetic-sensitive medical devices located within ≤ 30 centimeters of the TMS coil (for example cochlear implants, ICDs, pacemakers, VNS, deep brain stimulators, or metal aneurysm clips/coils/staples/stents) as contraindications or situations requiring special consideration.
Theta burst stimulation (TBS) is explicitly listed on the form as not medically necessary for all indications. Requests for TBS may therefore be denied. Providers must use the standard TMS parameters with FDA‑approved devices per manufacturer instructions and document device type when submitting an authorization request.
Providers submitting authorization materials should include the completed form with standardized depression rating scale scores, medication trial history, dates/doses/duration and adherence documentation, the specified FDA-approved device (if applicable), and the requested start date and number of sessions to allow review against these caveats.
Theta burst stimulation (TBS) is considered not medically necessary for all indications. The request form contains this explicit statement and indicates that requests for TBS may be denied.
Billing and Coding
| 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 |
Provider Actions and Documentation Requirements
Prior Authorization Required
Prior authorization is required for transcranial magnetic stimulation (TMS) services. Submit a completed Transcranial Magnetic Stimulation Request form to assist with timely review. Fax completed form to 866-834-7469 (toll-free). Include the member name, ID number, DOB, requesting provider information (physician name, provider NPI, tax ID), and requested start date and number of sessions/units.
- Affected services: TMS for major depressive disorder (see request form)
- Fax: 866-834-7469
Pharmacotherapy Trial Documentation
Document trials of pharmacotherapy for the current or prior depressive episode. The request must show inadequate response to pharmacotherapy despite: adequate dose and duration, documented adherence, and trials from two or more distinct medication classes. If pharmacotherapy could not be tolerated, document at least two trials with documented side effects and intolerance. Provide dates, maximum dose, duration, outcome, side-effects, adherence, and other relevant details for each medication trial.
- Require documentation of ≥2 medication classes tried with adequate dose/duration and adherence
- If intolerance is cited, provide ≥2 trials with documented adverse effects
Required Submission Documents
Required submission documents: a fully completed TMS request form including UM # (if received), member identifiers (name, ID #, DOB, current age), diagnosis and standardized rating scale initial and final scores with dates, specific TMS device (if used), requested start date and number of sessions/units, and requesting provider contact information (physician name, phone, fax, provider NPI, tax ID). For retreatment requests, include the prior authorization number if available and documentation showing prior response (≥50% reduction on a standardized rating scale) and recurrence.
- Completed Transcranial Magnetic Stimulation Request form (all sections)
- Standardized rating scales with initial and final scores and dates
- Provider NPI and Tax ID; physician signature and date
- If retreatment: prior auth number and documentation of prior response
Optional Supporting Documentation
Optional supporting documentation may be submitted to strengthen the request. This includes a copy of the TMS intake evaluation or a full psychiatric evaluation performed within three months prior to the requested start of treatment, and any additional clinical notes describing treatment history, suicide risk assessment, or functional impairment.
- TMS intake evaluation or full psychiatric evaluation within 3 months of requested start date (optional)
- Any additional clinical records relevant to treatment history
Denial Risk — Insufficient Prior Medication Trials
Insufficient documentation of prior medication trials may result in denial. Requests lacking clear evidence of trials from two or more medication classes, adequate dose/duration, or documented adherence (or documented intolerance as specified) are at risk for denial as not meeting medical necessity criteria.
- Denial risk if medication trial details (dates, doses, duration, adherence, outcomes) are missing or incomplete
Definitions
Background and Purpose
This form is used to collect the clinical information necessary to assess the appropriateness of transcranial magnetic stimulation (TMS) for members, with a primary focus on adults with treatment‑resistant major depressive disorder (MDD). It gathers standardized depression rating scale scores (initial and final with dates), confirmation of age and diagnosis, documentation of prior pharmacotherapy trials (including dates, doses, duration, outcomes, and adherence), safety screening for seizure risk and implanted magnetic‑sensitive devices, and the TMS device to be used when applicable.
The form also captures treatment intent (initial acute course, retreatment, continuation, or maintenance) and specifies the expected standard acute TMS course: up to 5 days per week for 6 weeks (total of 30 sessions) followed by a 3-week taper (3, 2, then 1 session). This information supports prior authorization review and aligns submitted requests with coverage criteria for TMS in treatment‑resistant MDD.
Level of Care Criteria
Treatment Modalities
TMS
form items; CPT codes listed for TMS delivery and management
Visit Limits and Session Limits
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