CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Navigated Transcranial Magnetic Stimulation (nTMS) for presurgical cortical mapping

Defines BCBSRI coverage stance for navigated transcranial magnetic stimulation (nTMS) used for localization of eloquent brain areas (motor and language) primarily in preoperative planning for brain surgery. Applies to commercial and Medicare Advantage products as described.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNavigated Transcranial Magnetic Stimulation (nTMS) for presurgical cortical mapping

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2020

Next Review Date

Key ActionFile claims for navigated TMS using unlisted CPT code 64999 and verify benefits; expect denials for nTMS used for presurgical mapping as it is considered not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coverednTMS for all purposes (including presurgical mapping)

Unlisted codeClaims filing requirement

2020-06-01Policy effective date

Coverage determination for navigated transcranial magnetic stimulation (nTMS)

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Clinical and evidence context

Navigated transcranial magnetic stimulation (nTMS) is a noninvasive cortical mapping technique that delivers magnetic pulses to cortical targets while registering the stimulation locations to the patient’s magnetic resonance image to identify motor and language sites. Surface electromyography is typically used to record responses from limb muscles during motor mapping, and disruptive effects on speech tasks are used to infer language-related cortical areas. The technology is evaluated as an alternative to intraoperative mapping and to other noninvasive modalities (eg, direct cortical stimulation [DCS], fMRI, MEG). (See: device description and method of mapping.)

Although nTMS can localize putative motor and language “hotspots,” the evidence base is limited. Studies comparing nTMS to the gold standard of DCS report variable accuracy; average distances between nTMS and DCS hotspots in many small studies are around 10 mm or less, but this does not account for measurement error, missed hotspots, or the fact that only exposed cortex can be verified intraoperatively. Language mapping studies in particular have demonstrated high false-positive rates (low specificity) and sensitivities that may be insufficient for reliable clinical decision making. Controlled observational outcome studies have had mixed results and methodological limitations, and did not consistently show improved clinical outcomes after presurgical nTMS. For these reasons, the evidence is insufficient to determine the effects of nTMS on health outcomes.

Because there is no specific CPT code for navigated TMS, claims for this service are filed using the CPT unlisted procedure code 64999. Use of nTMS for preoperative localization of eloquent brain areas (motor or language) or for other purposes is considered not covered / not medically necessary under this policy due to insufficient evidence that it improves health outcomes compared with established mapping approaches.

Key terms

Definitions

Direct Cortical Stimulation (DCS)An intraoperative technique where electrodes are applied directly to the cortical surface to identify eloquent brain areas; considered the gold standard for functional mapping.

nTMS / Navigated Transcranial Magnetic StimulationA noninvasive mapping technique that uses magnetic stimulation navigated over the patient’s MRI to identify cortical areas associated with motor or language function.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNavigated Transcranial Magnetic Stimulation (nTMS) for presurgical cortical mapping

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2020

Next Review Date

Key ActionFile claims for navigated TMS using unlisted CPT code 64999 and verify benefits; expect denials for nTMS used for presurgical mapping as it is considered not covered.

SourceLink

On This Page

OpenPayer

Navigated Transcranial Magnetic Stimulation (nTMS) for presurgical cortical mapping

Coverage determination for navigated transcranial magnetic stimulation (nTMS)

Billing and coding guidance

Actions, denial risk, and payer instructions

Clinical and evidence context

Key terms

Policy updates

Navigated Transcranial Magnetic Stimulation (nTMS) for presurgical cortical mapping

Coverage determination for navigated transcranial magnetic stimulation (nTMS)

Billing and coding guidance

Actions, denial risk, and payer instructions

Clinical and evidence context

Key terms

Also review

Policy updates