Transcranial Magnetic Stimulation (TMS) prior authorization checklist
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This document is a TMS treatment prior authorization and clinical checklist used by BlueCross BlueShield of Tennessee to collect member, provider, and clinical information to determine authorization for Transcranial Magnetic Stimulation for major depressive disorder in adults.
No material clinical or coverage changes in this revision.
Coverage Criteria for TMS
Initial Treatment Criteria
Information requested to support medical necessity for initial TMS treatment includes:
Form items 1,3-5,10-13 and pharmacotherapy grid must be completed.
Contraindications/Special Considerations
Contraindications/clinical exclusions queried on the form include:
Form items 2,6-9,10.
Maintenance/Extended Therapy
Maintenance/extended therapy
Form item 14.
The form specifically asks about psychotic symptoms in the current depressive episode and a range of neurologic conditions (for example, history of seizures/epilepsy, cerebrovascular disease, CNS tumors, prior severe or repetitive head trauma, increased intracranial pressure) as part of the clinical screening for TMS candidacy. Presence of these findings on the checklist will prompt further evaluation and may exclude the member from TMS or require additional clinical justification prior to authorization.
The checklist must be completed and signed to be processed; incomplete or unsigned forms may result in non-processing or denial of the authorization request. In addition, insufficient clinical information — such as absent documented diagnosis, missing psychiatric evaluation details, incomplete pharmacotherapy grid, or lack of informed consent/attestation — will likely affect processing and coverage determinations.
Billing and Coding
Provider Submission & Documentation Requirements
Prior Authorization Submission
Prior authorization is required. Submit the completed TMS Treatment Checklist with the requested number of units for each CPT code (90867, 90868, 90869) and the member/provider information. Include start and end dates of TMS service and relevant diagnosis codes. Tennessee providers may submit authorization requests via Availity; out-of-state providers may use their portal or Cohere. For assistance call (423) 535-5717, option 2.
Form Completion Requirement
Forms must be fully completed and signed by the provider to be processed. Incomplete or unsigned checklists may result in denial or return for completion. By submitting the request the provider attests that all provided clinical information is complete and accurate.
- Provider signature and date required on the Attestation
- All required fields on the TMS Treatment Checklist must be filled
Required Documentation
Submit the completed checklist containing member and provider information, DSM‑V diagnosis (e.g., major depressive disorder, severe), documentation of a psychiatrist evaluation (psychiatric history, mental status, past responses to antidepressants/TMS/ECT, current functioning), validated depression scale and score, and the pharmacotherapy grid with all past and current medications (dosage, start/stop dates, reasons for discontinuation).
- Completed TMS Treatment Checklist with member/provider info
- DSM‑V diagnosis (major depressive disorder, severe)
- Psychiatrist clinical evaluation: history, mental status, prior treatment responses
- Validated depression monitoring instrument and current score
- Pharmacotherapy grid with medication details, dates, and reasons for stopping
Therapy and Medication Trial Documentation
Document prior psychotherapy and pharmacotherapy trials: describe evidence‑based psychotherapy attempted (type, duration, frequency, and response) and complete the pharmacotherapy grid listing all antidepressant trials during the current and prior episodes, including doses, start/stop dates, and reasons for discontinuation. Also document prior TMS or ECT history, including dates and response or intolerance.
- Psychotherapy trial: type, duration, frequency, response to treatment
- Pharmacotherapy: all medications with dose, start/stop dates, and reason stopped
- Previous TMS or ECT history with dates and response/intolerance
Background
This TMS evaluation form is intended to assess adults being considered for Transcranial Magnetic Stimulation for major depressive disorder. It collects the patient’s age (minimum asked: 18+), pregnancy status, key neurologic and psychiatric contraindications, DSM‑V diagnosis confirmation, prior psychiatric history, details of past and current medication trials (pharmacotherapy grid), prior psychotherapy and ECT/TMS response, a psychiatric evaluation by an appropriately trained psychiatrist (history, mental status, current functioning), validated depression monitoring scores, and the provider attestation/signature to support a prior authorization decision.
Key Definitions
Level of Care Criteria
Treatment Modalities
TMS
Chunks 1 and 3 (provider info, CPT requests, and clinical checklist).
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