CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Authorization request form for Transcranial Magnetic Stimulation (TMS) services

This document is the prior authorization request form and instructions for Transcranial Magnetic Stimulation (TMS) services for Blue Cross Blue Shield of North Carolina members; it governs what providers must submit to request authorization and the information Blue Cross NC may require.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyAuthorization request form for Transcranial Magnetic Stimulation (TMS) services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with required clinical documentation (diagnosis, standardized rating scales, prior treatment trials, and rationale if ECT may be preferable) to request TMS authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

TMSservice covered by this form

Commercial & SHPmember types this form is for

866-987-4161submission fax

Blue Cross NC IDprovider identifier required

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Authorization supporting criteria

Authorization requests should include documentation that supports medical necessity for TMS. The form prompts for the following checks and criteria:

Core documentation and clinical criteria: Provider must supply a confirmed diagnosis of severe major depressive disorder (single or recurrent) documented by standardized rating scales; include current medications (dosages, duration), current psychological therapy (type, frequency, duration), detailed prior treatment history (service category, dates, reason for admission, response) and psychopharmacologic trials (drug, class, trial length, max dose, response). Indicate if rTMS is ordered as maintenance therapy and attach rating scale documentation.

From form fields requesting attachments and treatment history

Contraindications and risk checks: Identify presence of seizure disorder or any history of seizure; presence of acute or chronic psychotic symptoms or disorders in the current depressive episode (e.g., schizophrenia, schizophreniform, schizoaffective); neurologic conditions including epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of severe/repetitive head trauma, or CNS tumors; and presence of implanted magnetic-sensitive medical devices or other implanted items within 30 centimeters of the TMS coil (e.g., cochlear implant, pacemaker, ICD, vagus nerve stimulator, aneurysm clips/coils, staples, stents).

Form checklist identifies these as checks to determine increased risk or exclusion

ECT consideration: Provide rationale for why electroconvulsive therapy (ECT) would not be clinically superior to rTMS when typically indicated (examples include psychosis, acute suicidal risk, catatonia, or life‑threatening inanition).

Form explicitly requests this rationale

Maintenance/Extension requests: For extension of acute or for maintenance treatment, submit documentation of response to acute treatment, the goal/rationale for continued acute treatment, and a maintenance treatment rationale.

Form contains specific extension/maintenance sections

The form requires identification of clinical conditions that may contraindicate Transcranial Magnetic Stimulation (TMS). Specifically, it screens for the presence of acute or chronic psychotic symptoms or disorders (for example, schizophrenia, schizophreniform, or schizoaffective disorder) occurring during the current depressive episode. It also asks providers to indicate neurologic conditions including epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, a history of repetitive or severe head trauma, or primary or secondary central nervous system tumors. Finally, the form requires disclosure of any implanted magnetic-sensitive medical device or other implanted metal items (for example cochlear implants, implanted cardioverter defibrillators, pacemakers, vagus nerve stimulators, metal aneurysm clips/coils, staples, or stents) located within 30 centimeters of the TMS magnetic coil.

The form identifies situations in which repetitive TMS (rTMS) should not be used or where alternative therapy may be preferred unless a clear clinical justification is provided. It highlights psychosis (acute or chronic psychotic symptoms), acute suicidal risk, catatonia, and life‑threatening inanition as scenarios for which providers must address why electroconvulsive therapy (ECT) would not be clinically superior. For extension or maintenance requests the form specifically requests documentation of the response to acute treatment and the goal/rationale for continued or maintenance treatment to support ongoing rTMS.

Provider Submission and Documentation Requirements

Denial Risk

Incomplete submission risk

Submission of an authorization request form is required. Incomplete submissions may delay processing and do not guarantee approval. All NC providers must include their 5‑digit Blue Cross NC provider ID. Fax the completed form and required documentation to Blue Cross NC Commercial Behavioral Health at 866-987-4161.

Include patient name, Blue Cross NC ID number, DOB
Include requesting provider name and 5-digit Blue Cross NC provider ID
Incomplete forms may delay processing; submission does not guarantee approval

Documentation Required

Rationale and maintenance documentation required

If requesting extension of acute treatment or maintenance TMS, provide clear clinical rationale for continued therapy and document maintenance treatment goals. If ECT was considered, provide rationale for why electroconvulsive therapy is not clinically superior for this patient (e.g., psychosis, acute suicidal risk, catatonia, life‑threatening inanition are situations where rTMS should NOT be used).

For extension/maintenance requests include: response to acute treatment, goal/rationale for continued treatment, and explicit maintenance treatment rationale
If ECT is not pursued, state specific clinical reasons why ECT is not clinically superior

Documentation Required

Documentation of prior therapy trials

Provide detailed prior treatment history demonstrating failure of adequate trials of psychotherapy and psychopharmacologic agents. Attach standardized rating scales that reliably measure depressive symptoms and document dates, duration, dosages, maximum tolerated dose, and member response for each therapy trial.

Document failure of an adequate psychotherapy trial (type, frequency, duration, dates, and response)
List psychopharmacologic agents trialed with drug name, class, start/end dates, length of trial, max dose, and member response
Include standardized depression rating scales as separate attachments

Background

This authorization request form is specific to Transcranial Magnetic Stimulation (TMS) for treatment of depressive disorders and is used to request prior authorization for TMS services. The form collects patient identifiers, current medications (including dosages and duration), diagnostic information, and treatment history. It prompts providers to attach standardized rating scales to confirm diagnosis, document prior adequate trials of psychopharmacologic agents and psychotherapy, note any prior TMS treatments, and disclose contraindications or implanted devices that may increase risk. The form also includes fields for extension or maintenance requests requiring documentation of response to acute treatment and a clear maintenance rationale. Submission of the completed form with supporting clinical documentation is required to request authorization and may be subject to medical record review; incomplete forms may delay processing and submission does not guarantee approval.

Definitions

TMS — definition / key term

TermTranscranial Magnetic Stimulation (TMS)

Core definitionNoninvasive neuromodulation treatment for depressive disorders delivered using a magnetic coil placed over the scalp to stimulate cortical regions.

Documentation requiredConfirmed diagnosis of severe major depressive disorder documented by standardized rating scales that reliably measure depressive symptoms (attach scales).

Contraindications / risk checksPresence of psychotic symptoms in the current episode; seizure disorder or history of seizure; neurologic conditions (epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, CNS tumors, history of severe/repetitive head trauma); implanted magnetic‑sensitive devices or certain implanted metal items within 30 cm of the TMS coil.

ECT considerationProvider must provide rationale for why electroconvulsive therapy (ECT) would not be clinically superior when ECT is typically indicated (e.g., psychosis, acute suicidal risk, catatonia, life‑threatening inanition).

90867	CPT code listed on form (TMS-related procedure/authorization line item)
90868	CPT code listed on form (TMS-related procedure/authorization line item)
90869	CPT code listed on form (TMS-related procedure/authorization line item)

90867	CPT code listed on form (TMS-related procedure/authorization line item)
90868	CPT code listed on form (TMS-related procedure/authorization line item)
90869	CPT code listed on form (TMS-related procedure/authorization line item)

OpenPayer

Authorization request form for Transcranial Magnetic Stimulation (TMS) services

Coverage Criteria for TMS Authorization

Requested CPT / Billing Codes

Provider Submission and Documentation Requirements

Background

Definitions

Level of Care Settings

TMS Treatment Modalities