CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Transcranial Magnetic Stimulation (TMS) request form — prior authorization and documentation

This document is a provider-facing request form and checklist governing prior authorization and documentation for rTMS and dTMS services for members of Blue Cross and Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTranscranial Magnetic Stimulation (TMS) request form — prior authorization and documentation

Policy CodePolicy N/A

Change TypeAdministrative — form/update (no material clinical changes)

Effective DateN/A

Next Review DateN/A

Key ActionCall BCBSNM to check member benefits and fax the completed request form to BCBSNM for prior authorization, including CPT code(s) and number of sessions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

877-361-7659fax number to submit completed form

888-898-0070phone number to check benefits

rTMS / dTMStreatment modalities

Initial / Follow Uprequest types

Coverage and Medical Necessity Criteria

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General coverage considerations for TMS requests

Coverage consideration requires documented clinical information and absence of listed exclusions. Approval depends on meeting all of the following when applicable:

Basic documentation: Completed request form with ICD-10 diagnosis, treating provider information, requested service dates, CPT codes and number of sessions, and patient/member identifiers

Medication trials: Documentation of a trial of antidepressant medications (minimum of two) with medication name, class, maximum dose, and trial dates; for OCD document trial of TCA and SSRImin 2 medication trials (or TCA+SSRI for OCD)

Psychotherapy history: Patient currently or previously in psychotherapy known to effectively treat MDD (e.g., CBT) OR documented reasons psychotherapy cannot be done

Form captures current, past, or not possible options

Rating scales: Use of national standardized rating scales before, weekly during, and after treatment OR documented reason for not using them

Supports assessment of response

No exclusionary conditions: No presence of listed exclusionary conditions: seizure disorder (with specified exceptions), acute/chronic psychotic symptoms in current episode, certain neurological conditions, excessive alcohol/illicit substance use in last 30 days, prior nonresponse to rTMS defined as <50% reduction on standardized scale, or receipt of separate acute rTMS in past 6 months

Presence of any listed condition may lead to denial

The policy excludes coverage for members with certain medical and clinical conditions listed on the request form. Key exclusions include: seizure disorder or any history of seizures (with the exception of seizures induced by ECT or isolated febrile seizures in infancy without recurrence), acute or chronic psychotic symptoms or disorders during the current depressive episode (for example, schizophrenia or schizoaffective disorder), and specified neurological conditions such as epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, repetitive or severe head trauma, or primary/secondary central nervous system tumors. The form also lists recent excessive alcohol or illicit substance use within the last 30 days as an exclusionary condition, as well as prior treatment factors: no response to a prior course of rTMS (defined below) and receipt of a separate acute-phase rTMS treatment within the past 6 months. Presence of any of these exclusionary conditions may lead to denial of the request.

The request form defines prior lack-of-response to rTMS as "not achieving at least a 50% reduction in severity of scores for depression in a standardized rating scale (e.g., PHQ-9) by the end of the acute phase treatment". This ≥50% reduction threshold is used to identify prior nonresponse and is an exclusionary criterion when present.

Prior Authorization Steps and Documentation Required

Prior Authorization

Prior Authorization Required

Prior authorization is required. Provider must call Blue Cross and Blue Shield of New Mexico at 888-898-0070 to verify member benefits and eligibility prior to scheduling. Print, complete and fax the Transcranial Magnetic Stimulation (TMS) request form and supporting documentation to BCBSNM at 877-361-7659. Include requested service dates, CPT codes and number of sessions, request submission date, patient name, subscriber name, DOB, subscriber ID and group number.

Call BCBSNM 888-898-0070 to check benefits
Fax completed TMS request form and supporting documentation to 877-361-7659
Include CPT codes and number of sessions (e.g., 90867, 90868)
Indicate Initial Request or Follow Up Request and rTMS vs dTMS

Denial Risk

Medical Exclusion Risks (may preclude approval)

Approval may be denied for the presence of any exclusionary medical or clinical conditions. Review the checklist and document absence of contraindications on the request form.

Seizure disorder or any history of seizure disorder (except ECT‑induced or isolated febrile seizures in infancy without recurrence)
Acute or chronic psychotic symptoms or psychotic disorders in the current depressive episode (e.g., schizophrenia, schizoaffective disorder)
Neurological conditions: history of epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, repetitive/severe head trauma, or CNS tumors
Excessive alcohol or illicit substance use within the last 30 days
No response to a prior course of rTMS (defined as <50% reduction in standardized depression rating score by end of acute phase)
Prior separate acute phase rTMS treatment within the past 6 months

Documentation Required

Required Clinical and Administrative Information

Submit the completed clinical request form with required administrative and clinical information. Incomplete submissions may delay review or result in denial.

Provider name, address, contact name, email, phone, NPI and professional licensure
Requested service dates and request submission date
Patient name, patient DOB, subscriber name, subscriber ID and group number
Indicate Initial vs Follow Up request and rTMS vs dTMS
CPT code(s) and number of sessions requested
Manufacturer of TMS equipment (if available)
Current ICD‑10 diagnosis code, diagnosis name and specifier

Documentation Required

Rating Scale Documentation Requirements

Document use of standardized rating scales administered before treatment, weekly during treatment, and after treatment. List the specific scale(s) used and provide baseline and serial scores submitted with the request and follow‑up documentation.

Confirm whether national standardized rating scales were administered (Yes/No)
Specify rating scale being utilized (e.g., PHQ‑9, HAM‑D, Y‑BOCS for OCD)
Attach baseline score and weekly scores during the acute treatment phase and a post‑acute score
Note reason if rating scales were not used

Step Therapy

Medication Step Therapy Documentation

For Major Depressive Disorder (MDD) and Obsessive Compulsive Disorder (OCD) requests, document prior medication trials per step therapy requirements. Failure to document medication trials may trigger denial.

List a minimum of two adequate trials of antidepressant medications for MDD: include medication name, class, maximum dose, and start/end dates for each trial
For OCD, document trials of a tricyclic antidepressant (TCA) and a selective serotonin reuptake inhibitor (SSRI) with dates and dosing
If more than two trials were used, list additional medications with same details
If medication trials are not possible or are contraindicated, provide rationale and supporting documentation

Policy Background and Purpose

The TMS request form is the provider-facing tool used to initiate prior authorization for rTMS or dTMS services. It collects patient and member identifiers, indicates whether the request is an Initial or Follow Up request and requires specification of the chosen modality (rTMS or dTMS), CPT codes and number of sessions, treating provider information, and clinical documentation to support medical necessity. The form also asks whether national standardized rating scales were administered before, weekly during, and after treatment (or for the reason they were not used), and it prompts documentation of medication trials, psychotherapy history, and any exclusionary conditions noted above. Providers are instructed to call Blue Cross and Blue Shield of New Mexico to check member benefits and to fax the completed request form for prior authorization submission.

Transcranial Magnetic Stimulation Options

TMS (rTMS, dTMS) criteria group

Requests must specify the TMS modality and include the clinical documentation elements below. Approval requires meeting the general coverage considerations and modality-specific documentation on the form:

Modality selection: Request must specify rTMS OR dTMS on the form

Provider selects Initial or Follow Up and indicates modality on the request form

Treatment details: Provider must indicate CPT code(s) (90867 and/or 90868) and the number of sessions requested; include manufacturer of TMS equipment and requested service dates

Number of sessions must be specified on the form

Clinical entry criteria: Diagnosis documented with ICD-10 code and specifier; documentation of prior medication trials (minimum of two for MDD; TCA + SSRI for OCD) including medication name, class, maximum dose and trial dates; psychotherapy history or rationale for not doing psychotherapy

Used for initial requests

Monitoring and response: National standardized rating scales administered before, weekly during, and after treatment OR documented reason for not using them; ongoing requests should document clinical evidence of response or continued necessity

Supports assessment of treatment response

Exclusion screening: No presence of exclusionary conditions listed on the form (see exclusions): seizure disorder except specified exceptions; acute or chronic psychotic symptoms in current episode; specified neurological conditions; excessive alcohol/illicit substance use within last 30 days; prior nonresponse to rTMS (<50% reduction on standardized scale); receipt of separate acute rTMS in past 6 months

Presence may result in denial

OpenPayer

Transcranial Magnetic Stimulation (TMS) request form — prior authorization and documentation

Coverage and Medical Necessity Criteria

Billing Codes and Procedure Codes

Prior Authorization Steps and Documentation Required

Policy Background and Purpose

Key Definitions and Treatment Modalities

Level of Care / Site of Service

Transcranial Magnetic Stimulation Options

Session Counts and Visit Limits