CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Transcranial Magnetic Stimulation (TMS) treatment requests - Coverage Criteria

Covers requirements and information requested for authorization of transcranial magnetic stimulation (TMS) for depression and other indications submitted to Blue Cross Blue Shield - Wisconsin; affects providers requesting TMS services for members. The form documents clinical history, device, contraindications, prior treatment trials, and CPT/ICD coding for review.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyTranscranial Magnetic Stimulation (TMS) treatment requests - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization TMS request form including clinical history, device, treatment plan, number of sessions requested, and documentation of at least two adequate pharmacotherapy trials or intolerance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30standard acute treatment course (maximum)

>=18age requirement noted on form

2+minimum pharmacotherapy trials required

TBSnot medically necessary

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Initial TMS therapy

Covered when ALL of the following are met

Age: Individual is 18 years or older.

Diagnosis: Confirmed diagnosis of treatment-resistant major depressive disorder (single or recurrent episode).

Prior pharmacotherapy: Inadequate response to pharmacotherapy demonstrated by adequate duration and dosage, documented adherence, and trials from 2 or more classes; or inability to tolerate pharmacotherapy evidenced by 2 trials with documented side effects.2 medication classes

Provide medication trial details (dates, maximum dose, duration, outcome, adherence) on the request form.

Device and parameters: TMS administered by a U.S. FDA-approved device for treatment of MDD with stimulation parameters per manufacturer's user manual; specify device on form.

Treatment plan: Standard acute course not to exceed 5 days/week for 6 weeks (30 sessions) followed by a 3-week taper (3, then 2, then 1 session); number of sessions requested must be provided.30 sessions max

Requested start date and number of sessions/units must be provided on the form.

Documentation: Provide standardized rating scales (initial and final scores), medication trial details (dates, max dose, duration, outcome, adherence), and recent psychiatric evaluation if available.

Fax completed form and any supporting psychiatric evaluation within three months.

Retreatment

Retreatment criteria (when applicable)

Prior response: Previous response to TMS defined as 50% reduction in severity on a standardized rating scale from pretreatment.50% reduction

Provide authorization number for prior treatment if available.

Recurrence of depression must be documented by clinically meaningful worsening of symptoms relative to best TMS response on a standardized rating scale.

Authorization number for prior treatment should be provided if available.

The request form clarifies that Theta burst stimulation (TBS) is considered not medically necessary for all indications. Requests specifically for TBS may be denied and should not be submitted as a covered modality on the TMS request form. For TMS delivered for non-depressive conditions, the form requires the provider to explicitly indicate the targeted condition from a listed set (for example, obsessive-compulsive disorder, PTSD, migraine, Parkinson disease, chronic pain, etc.), but the policy treats TBS as not medically necessary regardless of indication.

Providers seeking authorization for non-depressive indications must complete the condition field on the form and supply supporting clinical documentation; however, the policy notes that many non-depressive uses are investigational or otherwise specified on the form and do not alter the standing exclusion that TBS is not medically necessary.

Theta burst stimulation (TBS) is considered not medically necessary for all indications. Requests that propose TBS as the stimulation paradigm are not covered under this policy and may be administratively or clinically denied.

Coding and Treatment Course

Covered CPT Codes (listed on request form)CPT

90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management
90868	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management; per session
90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; motor threshold re-determination with delivery and management; subsequent

Standard acute treatment course — session frequency and taper summary

Frequency and durationStandard acute course: up to 5 days/week for 6 weeks (maximum 30 sessions)

Taper schedule3-week taper after acute course: 3 sessions in week 1, 2 sessions in week 2, 1 session in week 3

Total maximum sessions30 acute sessions plus 6 taper sessions scheduled over 3 weeks

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for all Transcranial Magnetic Stimulation (TMS) services. Submit a completed Transcranial Magnetic Stimulation Request form to obtain prior authorization; include clinical details, device information, the proposed treatment plan, and the number of sessions requested.

Fax completed form to 866-834-7469 (toll-free).
Include member identifiers: name, ID #, DOB, current age, and provider information (physician name, NPI, tax ID, contact info).
Specify whether request is for initial treatment, retreatment, continuation, or maintenance and provide prior authorization number for previous TMS if applicable.

Documentation Required

Documentation Requirement: Inadequate Response to Pharmacotherapy

Document in the request that the individual has had an inadequate response to pharmacotherapy. Required documentation: evidence of trials from two or more antidepressant classes at adequate dose and duration, documentation of adherence to those trials, or documentation of inability to tolerate pharmacotherapy demonstrated by at least two trials with side effects.

List each medication trial with date, maximum dose, duration, outcome, side-effects, adherence, and other relevant information.
If inability to tolerate medications is claimed, provide documentation of adverse effects and the two trials supporting intolerance.

Prior Authorization

Submission Requirements: Completed TMS Request Form

Provide the fully completed TMS request form with the following elements to support timely review and authorization.

Member identifiers and contact information (name, ID #, DOB, address).
Clinical reason for TMS and diagnosis; standardized rating scale scores pre- and post-treatment when available.
Detailed medication history: list of medication trials (dates, doses, durations, outcomes, adherence, side effects) — include trials from 2+ classes as required.
Specify device to be used (FDA-approved device for MDD) and stimulation parameters per manufacturer instructions.
Treatment plan: requested start date, number of sessions/units, schedule (e.g., up to 5 days/week for 6 weeks with specified taper), and whether request is for initial, continuation, maintenance, or retreatment.
Safety information: history of seizures, implanted magnetic-sensitive devices, concurrent substance use that lowers seizure threshold, and any relevant neurological or psychotic conditions.
Attach any additional supporting documentation such as a TMS intake evaluation or a full psychiatric evaluation performed within 3 months of the requested start date.

Denial Risk

Denial Risk: Theta Burst Stimulation (TBS) and Retreatment

Requests for theta burst stimulation (TBS) may be denied as not medically necessary. Ensure documentation demonstrates prior adequate trials of pharmacotherapy and meets other policy criteria to reduce denial risk.

If TBS is requested, provide strong justification and complete prior treatment documentation (medication trials, adherence, intolerance) as required.
Retreatment requests must document prior meaningful response to TMS (e.g., ≥50% reduction on a standardized rating scale) and recurrence details.

Background

Transcranial magnetic stimulation (TMS) is requested primarily for treatment-resistant major depressive disorder (MDD) and the TMS request form is used to collect the clinical details needed for prior authorization. The form requires documentation that the individual had an inadequate response to pharmacotherapy — defined as adequate duration and dosage, documented adherence, and trials from 2 or more medication classes (or documented intolerance with two trials showing side effects) — and that the device to be used is a U.S. FDA–approved device with stimulation parameters per the manufacturer's user manual.

The form also captures safety and eligibility information (for example, seizure history, implanted magnetic‑sensitive devices, substance use affecting seizure threshold) and lists a broad set of non-depressive conditions for which TMS might be requested. It specifies the standard acute treatment course as not to exceed 5 days per week for 6 weeks (30 sessions) followed by a 3‑week taper, and it records CPT codes used for authorization and billing (for example, 90867, 90868, 90869).

Definitions

Retreatment definition

Retreatment (definition)Previous response to TMS defined as ≥50% reduction in severity on a standardized rating scale from pretreatment, plus documented recurrence of depression with clinically meaningful worsening relative to best TMS response.

AuthorizationProvide prior authorization number for the previous treatment if available.

Use in requestRequester must indicate whether the current request is for retreatment on the form.

Maintenance TMS — definition and remission context

DefinitionMaintenance TMS: treatment that continues after remission has been achieved.

Remission contextRemission is defined as virtual absence of depressive symptoms for at least 3 weeks; maintenance may end with relapse or recovery.

Request optionForm asks whether the request is for maintenance TMS and documents this intent.

OpenPayer

Transcranial Magnetic Stimulation (TMS) treatment requests - Coverage Criteria

Coverage Criteria for TMS

Coding and Treatment Course

What Providers Must Do

Background

Definitions

Level of Care

Treatment Modalities

Visit Limits and Session Counts