Transcranial Magnetic Stimulation (TMS) request and authorization form
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A provider-facing request form used to collect clinical, device, treatment-parameter, and prior-treatment information to support prior authorization of TMS (including rTMS and theta burst) for members of participating Blue Cross Blue Shield plans in listed states.
No material clinical or coverage changes in this revision.
Coverage Criteria for TMS
Initial TMS therapy
Covered when ALL of the following are met
Captured on form
Form asks to mark confirmed diagnosis
Medication trial details (dates, dose, duration, outcome, adherence) must be listed on form
Device type and treatment protocol recorded on form
Form lists specific devices (cochlear implant, ICD, pacemaker, VNS, DBS, aneurysm clips/coils/staples/stents) to check
Continuation and maintenance
Continuation or maintenance treatment considerations
Different documentation and prior response requirements apply
Form collects initial and final standardized rating scales and dates
Implanted magnetic‑sensitive medical devices or other metal objects located within 30 centimeters of the TMS coil are listed on the form as a safety concern and may preclude treatment. Examples called out on the form include cochlear implants, implanted cardioverter defibrillators (ICDs), pacemakers, vagus nerve stimulators (VNS), deep brain stimulators, and metal aneurysm clips/coils/staples/stents. Dental amalgam fillings are specifically noted as acceptable.
Billing and Coding
Provider Actions and Documentation Requirements
Prior authorization required — submit completed TMS request form with CPT codes
Complete and fax or submit the TMS request form (including the requested CPT codes) to obtain prior authorization before starting treatment. The form lists CPT 90867 for initial TMS (including cortical mapping and motor threshold determination) and 90868 for subsequent per‑session delivery and management.
Document prior pharmacotherapy — at least two adequate antidepressant trials
Document that the individual has had inadequate response to pharmacotherapy consisting of trials with two or more antidepressant classes, including adequate dose and duration and documented adherence; alternatively document inability to tolerate two trials with side effects.
- List each medication trial on the form with date of trial, maximum dose, duration, outcome, side effects, and adherence
- Specify if intolerance to two trials is the reason for proceeding to TMS
Required documentation — completed form (plus optional recent evaluations)
Submit the completed TMS request form; you may also include a copy of the TMS intake evaluation or a full psychiatric evaluation performed within three months of the requested start date to support the authorization, but these do not replace the required form.
- Include any relevant standardized rating scales, device type, and treatment parameters on the form
- Additional evaluations (TMS intake or psychiatric evaluation) may be attached if within 3 months of requested start
Implanted magnetic‑sensitive device proximity — exclusion/denial risk if ≤30 cm from coil
Marking that the individual has an implanted magnetic‑sensitive medical device or other metal item located less than or equal to 30 centimeters from the TMS coil is a safety exclusion and may preclude treatment or result in denial if not addressed.
- The form lists specific devices to check (e.g., cochlear implant, ICD, pacemaker, VNS, deep brain stimulator, metal aneurysm clips/coils/staples/stents)
- Dental amalgam fillings are explicitly acceptable and not affected
Background
This request form is used to obtain prior authorization for Transcranial Magnetic Stimulation (TMS) therapies — including repetitive TMS (rTMS) and theta burst stimulation (TBS) — for adults with severe major depressive episodes. The form collects the clinical information needed to determine coverage, including patient demographics and age, confirmed diagnosis, documentation of prior pharmacotherapy trials (number, dose, duration, and adherence), prior response to TMS when applicable, the specific device and stimulation parameters to be used, and the requested CPT codes and number of sessions.
Providers must complete and submit the form (including requested CPT codes such as 90867 for the initial session and 90868 for subsequent sessions) and include supporting documentation as indicated — for example, medication trial history, psychiatric evaluation or TMS intake evaluation within three months, and standardized rating scales when relevant — to support authorization and verification of criteria such as age (adult), inadequate response to at least two antidepressant classes, and device safety considerations.
The form also captures treatment-plan details and limits: whether TMS will be delivered by an FDA‑approved device (and which device), the intended stimulation modality (rTMS or TBS), and that the standard acute course is not to exceed five days per week for six weeks (a total of 30 sessions), followed by tapering when appropriate.
Definitions
Level of Care
Outpatient
Form documents criteria
Form captures response, treatment dates, and medication trials
Treatment Modalities
TMS / rTMS / TBS
Form contains checkboxes for TBS and rTMS types and space to specify protocol
Visit Limits and Session Counts
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