CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Transcranial Magnetic Stimulation (TMS) — Coverage Criteria

Policy governing coverage and coding for transcranial magnetic stimulation (TMS) for behavioral health/neurologic indications for adults, applicable to Blue Cross Blue Shield of Rhode Island members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTranscranial Magnetic Stimulation (TMS) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 5, 2024

Next Review DateN/A

Key ActionVerify member benefits and contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958 for prior authorization and coverage confirmation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Age indication

up to 30Typical visits

6 taperTaper sessions

7/1/2024New CPT codes effective

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General coverage criteria: Individual is 18 years of age or older; adequate trials of evidence-based psychotherapy and pharmacotherapy have been attempted without significant improvement; TMS is provided for depression or another psychiatric/neurologic brain disorder for which TMS is used; benefits and coverage are subject to the member-specific Evidence of Coverage and Subscriber Agreement.

Contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958 for case-specific guidance.

Benefits for transcranial magnetic stimulation (TMS) may vary by group and contract. Refer to the member’s Evidence of Coverage and Subscriber Agreement to determine applicable behavioral health benefits, coverage limits, and any member-specific exclusions or cost-sharing. For case-specific questions about coverage or authorization requirements, contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958.

Services that do not meet the policy’s specified criteria may be considered not medically necessary or non‑covered. Examples include treatment for individuals younger than 18 years and services provided without documentation of prior adequate trials of evidence‑based psychotherapy and pharmacotherapy. If a service is deemed a non‑covered benefit under the member’s Subscriber Agreement, the provider may not bill the member unless the member was informed and provided written agreement to pay in advance; verify member benefits before proceeding.

Coding and Billing

Medicare Advantage Plans and Commercial ProductsCPTCovered

0889T	Personalized target development for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation; includes data preparation and transmission, generation of the target motor threshold starting location, neuronavigation files and target report
0890T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation; including target assessment, initial motor threshold determination; initial treatment (report once on first day of course)
0891T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, treatment
0892T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation; neuronavigation, delivery and management; subsequent motor threshold redetermination with delivery and management; per treatment day
90867	Therapeutic repetitive transcranial magnetic stimulation treatment planning
90868	Therapeutic repetitive transcranial magnetic stimulation treatment delivery and management, per session
90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management

Typical course length

Typical course lengthUp to 30 visits over a 7-week period followed by 6 taper treatments

Initial course periodApproximately 7 weeks for the initial treatment series

Taper sessions6 taper treatments following the initial course

Provider Actions and Requirements

Prior Authorization

Prior Authorization / Benefit Confirmation

Prior authorization and benefit confirmation are required. Contact BCBSRI Behavioral Health Utilization Management to verify medical necessity and obtain any required prior authorization before initiating transcranial magnetic stimulation (TMS) services.

Verify member benefits against the Evidence of Coverage/Subscriber Agreement
Obtain prior authorization when required by the member's plan

Step Therapy

Step Requirement — Prior Treatment Trials

Prior to initiating TMS, document prior adequate trials of evidence-based psychotherapy and pharmacotherapy that demonstrate lack of significant improvement. Ensure records include medication names, doses, duration of trials, and psychotherapy details.

Document at least one adequate trial of evidence-based psychotherapy unless contraindicated
Document at least one adequate trial of pharmacotherapy (medication) with dose and duration

Note

Benefit Verification and Utilization Management Contact

Verify member-specific benefits and coverage limits against the Evidence of Coverage and Subscriber Agreement. For questions about coverage, authorization status, or to submit clinical documentation, contact BCBSRI Behavioral Health Utilization Management.

Confirm behavioral health benefit availability for the member's group/contract
Confirm any session limits, frequency limits, or site-of-service restrictions before scheduling

Denial Risk

Age and Prior-Treatment Requirement

TMS services are not covered for individuals under 18 years of age. Ensure documentation of prior adequate treatment trials is present to support medical necessity for members 18 and older.

Do not provide TMS for members under 18 — services for individuals <18 are not covered
Include prior-treatment documentation in the medical record to avoid denial risk

Background

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique in which a coil is positioned over the scalp to generate a magnetic field that induces cortical electrical stimulation. rTMS is used therapeutically for depression and other psychiatric or neurologic disorders. Treatment planning typically includes determination of the individual’s motor threshold to guide stimulation intensity, and the treatment target is commonly located several centimeters anterior to the motor site. Clinical courses frequently follow a protocol of multiple sessions delivered over several weeks.

Definitions

motor threshold

DefinitionMinimum stimulation intensity required to induce a motor response; empirically determined for each individual by stimulating the motor cortex and observing a contralateral muscle response

Determination methodLocalize scalp site for hand muscle stimulation and gradually increase intensity to identify threshold

Clinical useUsed to set stimulation parameters and for subsequent motor threshold re-determination during treatment courses

repetitive TMS (rTMS)

DefinitionRepeated delivery of TMS pulses for therapeutic effect (repetitive transcranial magnetic stimulation, rTMS)

IndicationsUsed to treat depression and other psychiatric/neurologic disorders

TechniqueNoninvasive coil placement over the scalp producing magnetic fields that induce cortical electrical stimulation

Treatment Modalities

MRI‑guided theta‑burst TMS

MRI‑guided theta‑burst stimulation codes: New CPT codes (0889T, 0890T, 0891T, 0892T) effective 7/1/2024 pertain to accelerated, repetitive high‑dose functional connectivity MRI‑guided theta‑burst TMS; include personalized target development, initial target assessment and motor threshold determination, treatment delivery, neuronavigation, and subsequent motor threshold redetermination; specific bundling and reporting restrictions apply (see coding).

Do not report 0889T with specified MRI imaging codes (70551–70555 or 77022); do not report 0892T on the same day as 0890T or 0891T; these codes are new effective 7/1/2024.

Standard rTMS

Standard TMS modalities: Therapeutic repetitive transcranial magnetic stimulation CPT codes 90867 (treatment planning), 90868 (treatment delivery and management, per session), and 90869 (subsequent motor threshold re‑determination with delivery and management) describe standard rTMS services and should be reported according to the service performed.

Use the appropriate CPT code based on whether the service is planning, per‑session delivery, or motor threshold redetermination.