CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Transcranial Magnetic Stimulation (TMS) prior authorization checklist

This document is a TMS treatment checklist and prior authorization form governing provider submission requirements for Transcranial Magnetic Stimulation services for BlueCross BlueShield of Tennessee members. It applies to providers requesting authorization for TMS treatment.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyTranscranial Magnetic Stimulation (TMS) prior authorization checklist

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit the completed TMS treatment checklist with requested CPT units (90867, 90868, 90869) and required supporting clinical documentation via Availity or provider portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13document chunks parsed

18+clinical checklist items

PHQ9, BDI, HAM-D, IDS-SR, MADRS, QIDSrecommended depression scales

90867/90868/90869CPT codes requested

Coverage Criteria for TMS Authorization

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Initial TMS authorization criteria

Covered when ALL of the following are met and documented on the form:

Adult age and diagnosis: Patient is at least 18 years of age and has a confirmed DSM-V diagnosis of major depressive disorder, severe.age >= 18

From checklist items on the form

Pregnancy status is documented (not pregnant or pregnancy considered) and any pregnancy-related risks have been addressed.

Checklist asks about pregnancy

Prior psychotherapy and pharmacotherapy trials: Evidence-based psychotherapy of adequate frequency was attempted without significant improvement and an adequate trial of pharmacotherapy is documented in the pharmacotherapy grid (medication names, dosages, start/stop dates, and reason stopped).documented psychotherapy and medication trials

Pharmacotherapy grid and psychotherapy questions required on form

ECT consideration: Either ECT is contraindicated, not tolerated, previously ineffective, or refused, with documentation provided regarding ECT status.documented ECT status

Form items ask about contraindication, prior response, or refusal of ECT

Psychotic symptoms exclusion: No psychotic symptoms are present in the current depressive episode (or if present, documented and addressed), since presence of psychotic symptoms affects candidacy for TMS.

Form asks about psychotic symptoms

Neurologic safety: No contraindicating neurologic conditions are present (epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, recent severe/repetitive head trauma, or CNS tumor), or these conditions are documented and evaluated as not precluding TMS.no contraindicating conditions

Checklist asks to document neurologic conditions

Medical stability: Patient is medically stable and comorbid medical conditions do not contraindicate TMS.

Form item asks if patient is medically stable for TMS

Prior TMS history: Prior courses of TMS (if any) are documented including date of last course and response.

Form asks about previous TMS and date of last course

Informed consent and evaluation: Patient or legal guardian understands purpose, risks and benefits and provides consent; there is documentation of a clinical evaluation performed by a psychiatrist appropriately trained in TMS including psychiatric history, past responses to antidepressant medication, past response to TMS, past response to ECT, mental status, and current functioning.signed consent and psychiatrist evaluation documented

Form items require consent and psychiatrist evaluation details

Monitoring plan: Validated depression monitoring instrument is selected and current score is provided to monitor symptom severity and treatment response (eg, PHQ9, BDI, HAM-D, IDS-SR, MADRS, QIDS).

Form lists validated depression scales and requests current score

Document and evaluate the presence of psychotic symptoms in the current depressive episode and any contraindicating neurologic conditions. The checklist explicitly asks whether the patient has psychotic symptoms and whether they have neurologic conditions such as epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary/secondary CNS tumors. Affirmative findings should be stated on the form and may exclude candidacy for TMS or require additional clinical justification and review.

Requests that are for maintenance therapy, continuous therapy, rescue therapy, or extended active therapy must be clearly identified on the checklist. The form asks whether the request is for any of these non-initial therapy categories; such requests are treated separately from initial authorization and may be reviewed under different criteria or denied if not supported by required documentation.

Provider Submission and Documentation Requirements

Prior Authorization

Prior authorization submission — attach completed checklist and requested CPT units

Submit the completed TMS Treatment Checklist with the requested number of units for each CPT code (90867, 90868, 90869) and supporting clinical information via Availity or the provider portal as specified on the form.

Specify units requested for CPT 90867, 90868, and 90869 on the form
Submit as an attachment through Availity (Tennessee providers) or the provider portal/Cohere (out-of-state providers)

Step Therapy

Therapy trials required — document psychotherapy and medication trials

Document that the patient had adequate trials of evidence-based psychotherapy and an adequate trial of pharmacotherapy (using the pharmacotherapy grid) without significant improvement before requesting TMS.

Describe type, duration, and response to psychotherapy on the form
Complete the pharmacotherapy grid with past and current medications, dosages, start/stop dates, and reasons for stopping

Documentation Required

Required submission documentation — complete all form fields and clinical sections

Provide the fully completed form including member and provider information, start and end dates of TMS service, number of units requested for CPT codes (90867, 90868, 90869), DSM-5 diagnosis, completed checklist items, documentation of psychiatric evaluation by a TMS-trained psychiatrist, and the pharmacotherapy grid.

Member/provider identifiers, facility address, and Tax ID
Start and end dates of service and units requested for 90867/90868/90869
DSM-V diagnosis confirmation and checklist items (age, pregnancy, contraindications, ECT status, consent)
Psychiatric evaluation details: psychiatric history, medication/TMS/ECT responses, mental status, current functioning
Pharmacotherapy grid with medications, dosages, dates, and reasons stopped

Denial Risk

Incomplete documentation risk — unsigned or incomplete forms may be denied

Incomplete or unsigned forms will not be processed; missing required checklist items or lack of documentation of a psychiatric evaluation by a TMS-trained psychiatrist may lead to denial of the authorization request.

Ensure the provider signature and date (attestation) are present on the form
Do not omit required checklist items (age, DSM-V diagnosis, psychotherapy/medication trials, ECT status, neurologic contraindications, consent, psychiatric evaluation)

Definitions and Monitoring Instruments

DSM‑V confirmation

DefinitionConfirmation that the patient meets DSM‑V diagnostic criteria for major depressive disorder, severe (documented on the form).

Age requirementPatient is at least 18 years of age (must be documented).

ConsentDocumentation that the patient and/or legal guardian understands purpose, risks, and benefits of TMS and provides consent (must be documented).

Psychiatric evaluationDocumentation of a clinical evaluation performed by a psychiatrist appropriately trained in TMS, including psychiatric history, past responses to antidepressant medication, past response to TMS and ECT, mental status, and current functioning (must be documented).

Depression monitoring scales

Primary instruments listedPHQ9, BDI, HAM‑D, IDS‑SR, MADRS, QIDS (provider must indicate which will be used).

Other instrument optionForm allows specification of other validated depression‑monitoring instrument (provider to name).

Current score requirementThe current score on the selected depression‑monitoring instrument must be provided on the form to document baseline severity and monitor response.

OpenPayer

Transcranial Magnetic Stimulation (TMS) prior authorization checklist

Coverage Criteria for TMS Authorization

Requested Procedure Codes

Provider Submission and Documentation Requirements

Background and Scope

Definitions and Monitoring Instruments

Level of Care — Outpatient Criteria

TMS Treatment Modality Criteria

90867	CPT code listed on form (provider to specify units)
90868	CPT code listed on form (provider to specify units)
90869	CPT code listed on form (provider to specify units)