CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Transcranial Magnetic Stimulation (TMS) — Medical Coverage Policy

Medical coverage policy describing when repetitive transcranial magnetic stimulation (TMS) is considered medically necessary for depression and other psychiatric/neurologic disorders for Blue Cross Blue Shield of Rhode Island members; applies to providers requesting authorization and billing for TMS services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTranscranial Magnetic Stimulation (TMS) — Medical Coverage Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 8, 2018

Next Review Date

Key ActionObtain prior authorization from BCBSRI Behavioral Health Vendor (800-274-2958) for BlueCHiP for Medicare and as recommended for Commercial products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 30typical recommended number of treatment visits

6 taper treatmentstypical taper period

3 codescovered TMS CPT codes

Coverage Criteria for TMS

Medical necessity

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CPT / Billing Codes

Covered CPT CodesCPTCovered

90867

Therapeutic repetitive transcranial magnetic stimulation treatment planning

Covered CPT CodesCPTCovered

90868

Therapeutic repetitive transcranial magnetic stimulation treatment delivery and management, per session

Covered CPT CodesCPTCovered

90869

Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold redetermination with delivery and management

Provider Responsibilities & Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare. For Commercial products, prior authorization is recommended. To request authorization, contact the BCBSRI Behavioral Health Vendor at 800-274-2958.

Applies to BlueCHiP for Medicare (required)
Recommended for Commercial products

Note

Benefit Variability by Contract

Benefits and any required utilization management (including prior authorization) may vary by contract. Providers must verify coverage and requirements in the member's Evidence of Coverage or Subscriber Agreement prior to delivering services.

Check the member's Evidence of Coverage or Subscriber Agreement for contract-specific benefits and requirements.

Documentation Required

Provider Notification Required

Participating providers must notify the BCBSRI Behavioral Health Vendor to ensure correct claims processing. Failure to notify may result in claims processing delays or denials. Contact: 800-274-2958.

Notify BCBSRI Behavioral Health Vendor to ensure correct claims processing
Contact number: 800-274-2958

Denial Risk

Risk of Denial if Authorization Not Obtained

If prior authorization is not obtained when required for BlueCHiP for Medicare, or if recommended prior authorization for Commercial products is not requested, services may be subject to claim denials or payment issues. Providers should obtain authorization per the instructions above before rendering non-emergent services.

Lack of required prior authorization for BlueCHiP for Medicare may lead to denial of payment
Not obtaining recommended authorization for Commercial products can risk claim processing problems

Background on TMS

Transcranial magnetic stimulation (TMS) is a noninvasive technique in which a coil is placed over the scalp and a rapidly alternating current produces a magnetic field that passes through the scalp and skull, inducing electrical stimulation of the cerebral cortex. Repetitive TMS is used as a treatment for depression and other psychiatric or neurologic disorders and is typically delivered as a course of treatments over several weeks.

Definitions and Terms

Transcranial Magnetic Stimulation (TMS) definition

DefinitionA noninvasive technique that uses a small coil placed over the scalp; a rapidly alternating current in the coil produces a magnetic field that passes through the scalp and skull and induces electrical stimulation of the cerebral cortex.

Also calledRepetitive transcranial magnetic stimulation (rTMS).

Therapeutic useUsed as a treatment for depression and other psychiatric/neurologic brain disorders.

Motor threshold

Motor threshold definitionThe minimum stimulation intensity required to induce a motor response, empirically determined for each individual by localizing a scalp site that evokes a hand muscle response and gradually increasing stimulation intensity.

PurposeUsed to calibrate individualized stimulation intensity for TMS treatment delivery.

LocalizationDetermined by identifying the motor cortex site that produces a contralateral muscle-evoked potential (typically a hand muscle).

Treatment Visit Limits

TMS treatment visits

Typical primary courseUp to 30 treatment visits over approximately a 7-week period.

ServiceRepetitive TMS treatment visits for depression and other psychiatric/neurologic disorders.

Vendor-determined continuationAdditional management or continuation beyond the typical course is determined by BCBSRI Behavioral Health Vendor criteria.

Taper treatments

Taper treatmentsApproximately 6 taper treatments following the primary course.

TimingTaper period typically follows the ~7-week primary treatment course of up to 30 visits.

PurposeUsed to gradually decrease stimulation after completion of the primary treatment course.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTranscranial Magnetic Stimulation (TMS) — Medical Coverage Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 8, 2018

Next Review Date

Key ActionObtain prior authorization from BCBSRI Behavioral Health Vendor (800-274-2958) for BlueCHiP for Medicare and as recommended for Commercial products.

SourceLink

On This Page

OpenPayer

Transcranial Magnetic Stimulation (TMS) — Medical Coverage Policy

Coverage Criteria for TMS

CPT / Billing Codes

Provider Responsibilities & Authorization

Background on TMS

Definitions and Terms

Level of Care / Setting

Treatment Modalities

Treatment Visit Limits