Transcranial Magnetic Stimulation (TMS) Prior Authorization Request Form — Outpatient TMS Coverage Criteria
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This form governs prior authorization submissions for outpatient Transcranial Magnetic Stimulation (TMS) services for members of BlueCross BlueShield of Tennessee; it specifies required clinical and administrative information the provider must supply to request coverage. It is a request form used to evaluate medical necessity for TMS treatment.
No material clinical or coverage changes in this revision.
Coverage Criteria for Prior Authorization
Initial Therapy Criteria
Authorization will be evaluated when the provider documents the following:
Questions on the form capture these items.
The prior authorization form includes a dedicated contraindications screen. It specifically asks whether the patient is pregnant, whether there are psychotic symptoms in the current depressive episode, and whether the patient has any neurologic conditions such as epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or CNS tumors. The form also asks the provider to confirm the patient is medically stable and that comorbid medical conditions are not contraindications to TMS.
The form states that it will not be processed if not signed or completed in full and warns that incomplete or unsigned submissions may be denied or not processed. Providers should ensure all required sections and the attestation/signature are present when submitting to avoid denial or non-processing.
Requested Codes
What Providers Must Submit
Submit prior authorization via Availity or fax with CPT units
Submit prior authorization requests online through Availity or fax the completed form (including requested CPT units) to 1-800-496-9600. The form identifies requested units for CPT codes 90867, 90868, and 90869 and requires those quantities to be provided on the submission.
Provide prior psychotherapy and pharmacotherapy history
The form requires documentation of prior treatments: whether evidence-based psychotherapy was attempted (with type, duration, and response) and a completed pharmacotherapy grid listing all past and current medications with dosage, start/stop dates, and reason stopped.
- Document if evidence-based psychotherapy was attempted and describe treatment type, duration, and response
- Complete pharmacotherapy grid with all past/current medications, dosage, start and stop dates, and reason why stopped
Provide required administrative and clinical documentation on the form
Include complete patient and provider administrative details and clinical documentation on the form: patient demographics and Subscriber ID, name and address of TMS psychiatrist and facility, start and end dates of TMS service, number of units requested for CPT 90867/90868/90869, diagnosis codes, age and pregnancy status, DSM‑V diagnosis confirmation, validated depression scale selection and baseline score, psychiatric evaluation details, and the completed medication grid.
- Patient name, DOB, phone, address, Subscriber name and Subscriber ID
- TMS psychiatrist name, facility name, psychiatrist/facility address, phone, fax, Tax ID
- Start and end dates of TMS service; number of units requested for CPT 90867, 90868, 90869; diagnosis codes
- Confirmation of age (≥18), pregnancy status, DSM‑V diagnosis of major depressive disorder, severe
- Validated depression monitoring instrument selection and current score; psychiatric history and mental status exam; completed pharmacotherapy grid
Do not submit incomplete or unsigned forms
The form will not be processed if it is not signed or completed in full; incomplete or unsigned submissions may be denied or not processed.
- Provider signature and date required on attestation section
- Ensure all checklist items and clinical fields are completed before submission
Setting / Level of Care
Treatment Modalities Covered
TMS
Key Definitions and Screening Items
Background
This request form is used to evaluate outpatient Transcranial Magnetic Stimulation (TMS) for adults with severe major depressive disorder. Authorization requires documentation that the patient is at least 18 years of age, has a confirmed DSM‑V diagnosis of major depressive disorder, severe, and that evidence‑based psychotherapy or adequate pharmacotherapy trials were attempted without significant improvement. The form also requires a psychiatric evaluation by a psychiatrist trained to provide TMS, documentation of prior responses to antidepressant medication, TMS or ECT, assessment of medical stability and contraindications, selection of a validated depression monitoring instrument with baseline score, and the provider attestation/signature.
Visit Limits and Units
Revision History
Form will not be processed if it is not signed or completed in full; incomplete or unsigned submissions may be denied or not processed.
Provider attestation and signature required on the form; provider must certify information is true and complete and provide signature and date.
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