Blue Cross Blue Shield - Wisconsin TMS Prior Auth

Coverage criteria for TMS

Initial TMS treatment criteria

Covered when ALL of the following are met:

Primary diagnostic and demographic criteria: Individual is an adult with a confirmed diagnosis of severe major depressive disorder (single or recurrent episode).

Prior treatment trials: Individual has failed to significantly respond to prior treatment OR is unable to tolerate psychopharmacologic agents as evidenced by four trials; treatment trials have included at least two different agent classes at or above the minimum effective dose and duration; and trials have included at least two evidence-based augmentation therapies when indicated.four trials; >=2 agent classes

Document medication name, trial dates, maximum dose, duration, and outcomes on the form.

Prior TMS or ECT considerations: Individual has history of response to TMS in a previous depressive episode with >50% improvement on a standard rating scale OR individual is currently receiving ECT and TMS is considered a less invasive option OR individual is a candidate for and has declined ECT.>50% improvement for prior TMS

Specify which standardized rating scale was used to document response.

Psychotherapy documentation: Individual has had a trial of evidence-based psychotherapy with adequate frequency and duration and documentation of outcomes by standardized rating scales as applicable.

Specify psychotherapy model and provide rating scale results.

Device and treatment parameters: TMS will be administered by an FDA-approved device in accordance with the manufacturer's user manual; proposed treatment is consistent with FDA/manufacturer parameters (five days per week for six weeks, total 30 sessions, followed by a three-week taper) unless deviation is justified.FDA parameters preferred

Specify device if applicable and indicate proposed number of units per week.

Contraindications: Individuals with acute or chronic psychotic symptoms in the current depressive episode, specified neurological conditions (epilepsy, cerebrovascular disease, dementia, increased intracranial pressure), history of severe head trauma, CNS tumors, or implanted magnetic-sensitive medical devices located ≤30 cm from the TMS coil are safety concerns that may preclude treatment and must be documented and mitigated if present.

Form lists implantable devices (eg, cochlear implant, pacemaker, ICD, VNS, metal aneurysm clips/coils/staples/stents); dental amalgam is acceptable.

Maintenance TMS

Maintenance TMS requests:

Maintenance request: If requesting maintenance TMS, indicate that this is a maintenance request, provide the date of the most recent treatment, and submit any additional relevant clinical documentation (for example, TMS intake evaluation or full psychiatric evaluation) within three months of the requested start date.

Individuals with implanted magnetic-sensitive medical devices located ≤30 cm from the TMS coil or with certain neurological conditions are identified as safety concerns. The policy lists implanted magnetic-sensitive devices within 30 centimeters of the coil (examples: cochlear implant, implanted cardioverter defibrillator, pacemaker, vagus nerve stimulator, metal aneurysm clips/coils/staples/stents, or other specified devices) as potential exclusions. Dental amalgam fillings are explicitly noted as acceptable and not affected by the magnetic field. Additionally, specified neurological conditions — including epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, and primary or secondary CNS tumors — are listed as safety concerns that may preclude treatment unless adequately mitigated and documented.

Requests for individuals who have these safety contraindications may be handled specially and could be considered not medically necessary without sufficient mitigation or documentation. The form requires providers to indicate the specific device or neurologic condition and to document any rationale or steps taken to address the risk. If an implanted magnetic-sensitive device is present within 30 centimeters of the coil or a listed neurologic contraindication exists, include detailed clinical information and justification to support safe administration or alternative treatment planning.

Coding and device parameters

inv-05: FDA/manufacturer stimulation parameters

Manufacturer/FDA recommended scheduleFive days per week for six weeks (total 30 sessions), followed by a three-week taper (week 1: 3 treatments; week 2: 2 treatments; week 3: 1 treatment).

Device requirementTMS must be administered by an FDA-approved device per the manufacturer's user manual; specify device if indicated on form.

Deviation documentationProposed treatment should match FDA/manufacturer parameters unless provider documents deviation and clinical justification.

inv-06: Prior TMS response threshold

Prior TMS response thresholdGreater than 50% improvement in depressive symptoms on a standard, reliable rating scale documented from prior TMS treatment.

Required documentation

Submission, documentation, and denial triggers

Prior Authorization

Submission and signature requirement

Please submit authorization requests electronically via our preferred portal: https://Availity.com. If electronic submission is not possible, you may fax the completed form to the appropriate behavioral health fax number listed below. The care provider (or authorized signer) must sign and date the form to affirm that the information is accurate and complete based on clinical assessment and available records as of the request date.

Preferred submission: https://Availity.com
If unable to submit electronically, fax to the appropriate BH fax number listed below (see chunk 10)
Provider signature and date required on the form to attest accuracy

Documentation Required

Required supporting documentation

Include documentation that supports the clinical need for TMS. Attach copies of relevant clinical records (within three months of the requested start of treatment) such as intake evaluation, full psychiatric evaluation, and treatment history. Provide information on prior medication and psychotherapy trials, standardized depression rating scales and scores, and any assessment for ECT with rationale if ECT was not used.

Background and scope

Transcranial Magnetic Stimulation (TMS) is requested primarily for adults with major depressive disorder and is administered using an FDA-approved device following the manufacturer's user manual. The intake form captures prior pharmacologic and psychotherapy treatment trials, prior response to TMS when applicable, and safety screening for device- and neurologic-related contraindications. Key safety screening items include standardized depression rating scale selection (for example, PHQ-9 or QIDS), confirmation that an FDA-approved device will be used, and explicit documentation of any implanted magnetic-sensitive devices or neurologic conditions that could affect the safety of TMS.

Definitions and terms

inv-13: Augmentation therapy definition

DefinitionAugmentation therapy: a drug regimen consisting of one or more drugs added to an antidepressant to increase its efficacy (example: adding pindolol to fluoxetine).

PurposeUsed when monotherapy with an antidepressant has not produced adequate response; documented as part of prior treatment trials on the form.

DocumentationForm asks that treatment trials include at least two evidence-based augmentation therapies when applicable.

Level of care — outpatient

Treatment modalities considered

TMS

TMS modality: Transcranial Magnetic Stimulation administered by an FDA-approved device in a safe and effective manner per the manufacturer's user manual; document the device and proposed stimulation schedule. Treatment course should not exceed five days per week for six weeks (30 sessions) followed by a three-week taper unless a deviation is documented and justified.Five days/week x 6 weeks (30 sessions) + 3-week taper

Specify device if marked on form.

ECT (comparative)

ECT consideration: Document if the individual is currently receiving ECT and TMS is considered a less invasive option, or if the individual is a candidate for and has declined ECT.

If applicable, note rationale why ECT is not being used.

Treatment course and visit limits

inv-17: TMS treatment course

Initial course lengthInitial treatment course: 30 sessions over six weeks (five sessions/week) per FDA/manufacturer parameters.

Taper scheduleThree-week taper following the 6-week course: week 1 = 3 treatments, week 2 = 2 treatments, week 3 = 1 treatment.

Visit limits periodCourse period described as 6 weeks plus 3-week taper on the form; proposed units per week are captured if deviations occur.

OpenPayer

Transcranial Magnetic Stimulation (TMS) testing request — coverage criteria