CurrentBluecross IdahoPolicy MP 3.01.550

Repetitive Transcranial Magnetic Stimulation (rTMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

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Coverage and medical necessity criteria for rTMS and deep rTMS for major depressive disorder and other psychiatric/neurologic disorders for Blue Cross of Idaho members; describes required documentation, contraindications, treatment course limits, and investigational indications.

Policy Summary

PayerBluecross Idaho

PolicyRepetitive Transcranial Magnetic Stimulation (rTMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

Policy CodePolicy MP 3.01.550

Change TypeNo material changes

Effective DateMay 28, 2026

Last ReviewMay 28, 2026

Next Review DateMay 28, 2026

Key ActionSubmit prior authorization with legible clinical documentation from the recommending psychiatrist or PMHNP including diagnosis, standardized depression scale scores, prior medication/augmentation and psychotherapy trials, and absence of contraindications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36acute phase rTMS sessions authorized

30usual maximum sessions over 6 weeks

50%prior positive response threshold for retreatment

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CurrentBluecross IdahoPolicy MP 3.01.550

Repetitive Transcranial Magnetic Stimulation (rTMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

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Policy Summary

PayerBluecross Idaho

PolicyRepetitive Transcranial Magnetic Stimulation (rTMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

Policy CodePolicy MP 3.01.550

Change TypeNo material changes

Effective DateMay 28, 2026

Last ReviewMay 28, 2026

Next Review DateMay 28, 2026

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36acute phase rTMS sessions authorized

30usual maximum sessions over 6 weeks

50%prior positive response threshold for retreatment

18+minimum patient age for covered rTMS

Apr 9, 2026evidence search through

Coverage and Medical Necessity Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial rTMS coverage for MDD: 1. Age 18 years or older

Confirmed diagnosis: 2. Confirmed diagnosis of severe major depressive disorder (single or recurrent) documented by a standardized, validated rating scale; baseline and follow-up assessment using the same scale before and within 1–2 months after the acute phase

Medication/augmentation trials: 3. Any one of the following: (a) inadequate response to ≥2 antidepressant agents from ≥2 different classes AND inadequate response to ≥2 augmentation trials (adequate trial = ≥6 weeks at maximally tolerated/clinically effective dose); OR (b) documented intolerance to ≥2 antidepressants with FDA‑labeled contraindication to major classes; OR (c) patient‑specific barriers to electroconvulsive therapy (ECT)

Adequate trial defined as ≥6 weeks with dose titration to maximally tolerated/clinically effective dose.

Psychotherapy trial: 4. Failure of an adequate psychotherapy trial (evidence‑based therapy) of adequate frequency and duration (not less than 4 months per episode) without significant improvement, documented by standardized rating scales and written therapist documentation addressing length, attendance, progress, and treatment type

Contraindications absent: 5. No contraindications to rTMS (examples include seizure disorder or history of unprovoked seizures except ECT‑induced or isolated febrile seizures in infancy; acute or chronic psychotic symptoms in the current episode; neurologic conditions such as epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, prior severe head trauma, CNS tumors; excessive alcohol or illicit substance use within last 30 days; implanted magnetic‑sensitive devices or metal within proximity to the coil as specified)

If criteria are met, up to 36 acute phase sessions may be authorized; typical course not to exceed 5 days/week for 6 weeks (30 sessions) followed by a 3‑week taper (3, 2, then 1 session).

Subsequent/Retreatment

Subsequent rTMS (retreatment) covered when ALL of the following are met:

Prior positive response: 1. Documented positive response to a prior acute rTMS course, defined as ≥50% reduction in depression severity on the same standardized, validated rating scale with pre‑ and post‑acute phase scores≥50% reduction

Timing since prior acute phase: 2. No separate acute phase rTMS treatment received within the last 6 months<6 months since prior acute phase not met for coverage

Contraindications absent: 3. Patient continues to have no contraindications to rTMS (as listed for initial therapy)

Assessment and order: 4. A psychiatrist (MD/DO) or PMHNP has reassessed the patient and provided an order for subsequent treatment with documentation in the medical record

Investigational/Not Medically Necessary

Investigational uses: rTMS is investigational (not medically necessary) for: patients who did not respond to prior rTMS (did not achieve ≥50% reduction by end of acute phase), use as maintenance/booster treatment for depression, and use for all other psychiatric or neurologic disorders not meeting specified coverage criteria (including but not limited to bipolar disorder, schizophrenia, OCD, migraine headaches) unless specific coverage criteria are met

Treatment-Resistant Depression coverage context

Covered when clinical evidence supports use in the indicated population and device is appropriate for the clinical context

TRD primary criteria: Patient has treatment‑resistant depression (TRD) as defined in clinical trial contexts and clinical documentationas defined in clinical context

TRD population is the primary focus of review

Intervention: Planned rTMS modality and parameters (conventional rTMS, deep rTMS, theta‑burst, or accelerated protocols) are consistent with those studied or with FDA‑cleared device indicationsdevices/parameters consistent with trials or FDA clearance

Comparators considered: Comparative context includes pharmacotherapy, psychotherapy, and electroconvulsive therapy (ECT); rTMS is considered as alternative or adjunct based on this evidence basen/a

Eligibility mirroring trial entry

Coverage considerations derived from clinical trial populations and typical inclusion criteria

Typical TRD inclusion logic: Patient has major depressive disorder with treatment resistance commonly defined in trials as failure of ≥2 adequate antidepressant trials (some trials excluded patients who failed >3 trials); request specifies rTMS modality (conventional, theta‑burst, deep TMS, or accelerated) and treatment schedule (e.g., once daily 5x/week for 4–6 weeks or accelerated multiple sessions/day), and baseline depression severity scores are documented (e.g., MADRS, HAM‑D)>=2 failed antidepressant trials

Some trials required imaging‑guided targeting or limited prior failures

Maintenance therapy

Maintenance/relapse-prevention context

Maintenance options studied: Maintenance strategies evaluated include weekly low‑frequency rTMS, tapering schedules (decreasing session frequency over weeks), or maintenance pharmacotherapy (e.g., lithium) as comparators; one randomized trial found similar relapse rates between weekly low‑frequency rTMS and lithium at 24 weeks24 weeks follow‑up in trial

Evidence on maintenance durability and optimal schedule is limited; choice may depend on tolerability and adverse events

Treatment-Resistant Depression — Evidence Summary

Evidence summary for treatment-resistant depression and accelerated protocols

TRD evidence summary: Meta‑analyses and numerous sham‑controlled RCTs demonstrate improved response and remission for conventional rTMS and theta‑burst stimulation versus sham; a head‑to‑head trial showed noninferiority of iTBS to conventional rTMS; accelerated protocols have shown large short‑term effects in small RCTs (including fMRI‑guided SNT) but long‑term durability and generalizability remain uncertain

Supports consideration of coverage with criteria requiring prior treatments and standardized outcome assessment

Migraine Headache — Evidence Summary

Evidence summary for migraine headache

Migraine evidence summary: Systematic reviews of RCTs using high‑frequency left DLPFC rTMS reported reductions in migraine days and pain intensity versus sham, but pain intensity differences may be clinically insignificant; a pivotal Cerena RCT (N=201) reported post‑hoc benefits in a subgroup (pain‑free at 2 and 24 hours) but had high dropout (46%) and reliance on post hoc analyses limits certainty; FDA labeling notes lack of demonstrated safety/effectiveness for cluster headache, chronic migraine, or treatment during aura, and limited effect on associated symptoms (photophobia, phonophobia, nausea)

Evidence limitations may constrain coverage to specific migraine presentations or require prior therapy failure

Obsessive-Compulsive Disorder — Evidence Summary

Evidence summary for obsessive-compulsive disorder

OCD evidence context: Multiple small‑to‑moderate sham‑controlled RCTs and meta‑analyses report small‑to‑moderate improvements in YBOCS versus sham; an RCT of deep TMS (Carmi et al. 2019, N=99) showed benefit in a modified‑ITT analysis but not significant difference on ITT for the primary outcome and secondary outcomes were mixed; an improvement of ≥35% on the YBOCS is most predictive of treatment response, and accelerated protocols show short‑term benefit with uncertain durabilityYBOCS improvement >=35% predictive

Coverage considerations should reference baseline YBOCS severity and prior CBT/SRI trials to mirror trial populations

Evidence synthesis (no explicit coverage determination in excerpt)

Evidence-based findings from systematic reviews and RCTs relevant to coverage decisions

Systematic review evidence: Multiple systematic reviews and meta‑analyses report that certain rTMS protocols (high‑frequency bilateral DLPFC, high‑frequency deep TMS over dmPFC/ACC, low‑frequency right DLPFC, and accelerated TMS) have shown statistically significant improvements in YBOCS or symptom scores versus sham in pooled analyses, but heterogeneity, short follow‑up, and variable targets limit certainty

Key RCT (Carmi et al 2019) showed modified‑ITT benefit but non‑significant ITT primary outcome

Key RCT (Carmi et al 2019): In the Carmi et al. deep TMS sham‑controlled RCT (N=99), modified‑ITT analysis (n=94) showed greater mean YBOCS decrease and higher response rates (38.1% vs 11.1%); ITT analysis difference in mean change was not statistically significant and secondary outcomes were mixed

Limitations include sample size and analysis approach

Evidence considerations (non-depression/migraine/OCD)

Evidence synthesis and considerations for rTMS in psychiatric/neurologic disorders other than depression, migraine, or OCD

General evidence summary: For indications other than depression, migraine, or OCD (e.g., bipolar disorder, GAD, panic disorder, PTSD, schizophrenia, substance use/craving, ALS, chronic pain, fibromyalgia, Parkinson disease, stroke recovery), the evidence consists of numerous small RCTs and meta‑analyses with heterogeneous protocols and limited sample sizes; overall quality is low and results are inconsistent, with no large high‑quality trials demonstrating durable benefit

Insufficient evidence to determine improvement in net health outcome for most non‑depression indications

Disorder‑specific notes: Examples: bipolar disorder trials show mixed efficacy with concerns about bias; GAD meta‑analyses report symptom reductions but heterogeneity; PTSD reviews show variable effects and low certainty; schizophrenia safety analyses indicate higher rates of headache and related events but low seizure prevalence

Refer to systematic reviews cited for condition‑level detail

Evidence-informed coverage considerations

Evidence summaries and meta-analytic findings included in this section inform coverage determinations:

Substance use and craving: Meta‑analyses report medium‑to‑large effect sizes for rTMS reducing craving in substance dependence and methamphetamine use disorder, but studies are small and heterogeneous; subgroup analyses suggest iTBS may outperform 10‑Hz in some analyses

Further larger trials needed

Chronic pain and neuropathic pain: Systematic reviews show small short‑term effects for chronic pain that did not meet minimum clinically important difference thresholds; neuropathic pain meta‑analyses found moderate effect sizes but with heterogeneity and need for larger trials

Short‑term benefit; low‑to‑moderate quality evidence

Amyotrophic lateral sclerosis (ALS): Cochrane review and small RCTs for ALS are of poor quality and limited in number; evidence insufficient to determine efficacy or safety

Insufficient evidence

TRD — Covered with clinical criteria

Covered when clinical evidence supports use in the indicated population and device is appropriate for the clinical context

TRD coverage stance: rTMS (including conventional high‑frequency protocols and iTBS) may be considered a treatment option for patients with treatment‑resistant depression based on multiple sham‑controlled RCTs and meta‑analyses showing improved response and remission rates; accelerated protocols show short‑term benefit in some RCTs but long‑term durability is uncertain

Evidence deemed sufficient to conclude improvement in net health outcome for TRD when criteria (prior treatments, documentation, and safety) are met

Not established / Insufficient evidence

Conditions with insufficient or mixed evidence where rTMS is not established as improving net health outcome

Migraine: Systematic reviews and a pivotal FDA‑submission trial showed reductions in pain intensity and frequency but limitations (high dropout, post hoc analyses) and no recent confirmatory studies; evidence insufficient to determine net health benefit for broader migraine indications

FDA labeling restricts some migraine uses (cluster, chronic migraine, during aura)

Obsessive‑Compulsive Disorder (OCD): Some RCTs and meta‑analyses show small‑to‑moderate effects on YBOCS scores with benefits often diminishing by ~4 weeks; pivotal deep TMS RCT had mixed ITT results and limited durability—evidence considered insufficient for durable net health outcome for routine coverage without trial‑mirroring criteria

Consideration may be given in trial‑like patients but durability and functional benefit uncertain

Other psychiatric/neurologic disorders: For bipolar disorder, GAD, panic disorder, PTSD, schizophrenia, substance use/craving, ALS, chronic pain, epilepsy, fibromyalgia, Parkinson disease, and stroke recovery, trials are small, heterogeneous, and of low quality; no large high‑quality trials demonstrate efficacy or durability—evidence insufficient

Guideline-based coverage considerations

Guideline‑referenced coverage considerations and consensus statements

Professional guidance notes: APA (2018) recognizes multiple RCTs supporting safety and efficacy of rTMS for depression and outlines operational variables (environment, operator requirements, motor threshold determination, session number); NNDC/Clinical TMS Society consensus (2025) recommends iTBS or high‑frequency rTMS as appropriate initial antidepressant protocols and suggests a full treatment course of 30–36 sessions and characterizes maintenance evidence as promising but unclear on frequency; VA/DoD (2022) suggests offering rTMS after inadequate response to ≥2 adequate pharmacologic treatments (weak recommendation)

Guideline statements inform coverage considerations but do not replace insurer‑specific authorization rules

Explicit contraindications and exclusions in the policy include: a history of seizure or any condition with increased seizure risk; presence of acute or chronic psychotic symptoms or psychotic disorders during the current depressive episode (e.g., schizophrenia, schizoaffective disorder); neurologic conditions such as epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, prior repetitive or severe head trauma, or primary/secondary CNS tumors; recent excessive alcohol or illicit substance use within the last 30 days; and implanted magnetic‑sensitive devices or other implanted metal items located ≤30 cm from the TMS coil (examples: cochlear implant, pacemaker, implanted cardioverter defibrillator, vagus nerve stimulator, aneurysm clips/coils, staples, stents).

Policy history documents that a contraindication for recent excessive alcohol or illicit substance use was added in a prior update; the policy also specifies that if contraindications are absent and other coverage criteria are met, up to 36 acute phase sessions may be authorized with a typical acute course not to exceed 5 days per week for 6 weeks (30 sessions) followed by a 3‑week taper. Requests lacking required legible clinical documentation from an appropriately credentialed treating clinician (psychiatrist MD/DO or PMHNP) may be denied.

FDA clearances and device labels impose population‑specific cautions that may affect clinical use and coverage. For migraine devices (e.g., Cerena), labeling limits use to patients experiencing onset of pain associated with migraine with aura and explicitly indicates the device has not been demonstrated safe or effective in pregnant women, children <18 years, and adults >65 years; it should not be used for headaches due to underlying pathology/trauma or for medication‑overuse headache.

The policy notes multiple rTMS systems cleared for adolescent use in specific age ranges and that regulatory device indications and warnings have been considered in prior policy updates; deviation from intended regulatory populations or labeled contraindications may lead to request denial.

Comparative evidence versus electroconvulsive therapy (ECT) shows ECT favored in some trials: pooled analyses comparing rTMS with ECT demonstrated a clinically and statistically greater improvement with ECT (weighted mean difference in HAM‑D in one review was ~5.97 points favoring ECT), though findings varied across studies. The policy highlights that ECT may be preferred for more severe presentations (for example, psychotic depression) where greater clinical improvement is needed.

When considering rTMS versus ECT in coverage decisions, the relative effect sizes, durability of response, and patient‑specific factors (severity, psychosis, prior treatment tolerance) should be weighed; the policy states rTMS effect sizes are generally smaller than ECT and durability may be more limited.

FDA labeling for migraine devices explicitly states lack of demonstrated safety or effectiveness for treatment of cluster headache, chronic migraine, and for use during the aura phase. The labeling also indicates limited evidence for relief of associated migraine symptoms (photophobia, phonophobia, nausea).

Because these regulatory limitations are explicit in device labeling, requests for rTMS for cluster headache, chronic migraine, or treatment during aura should be evaluated with caution and may be considered unsupported by the regulatory evidence base.

Randomized trials generally excluded participants whose primary Axis I diagnosis was other than the target disorder (for example, trials of deep TMS for OCD enrolled adults with OCD as the primary disorder), excluded individuals with severe neurologic impairment or other conditions that increase risk, and required stability of concurrent treatments (e.g., therapeutic SRI dosing for ≥2 months in the Carmi et al. OCD trial). Similar eligibility patterns are described across RCTs and guided the policy's trial‑mirroring coverage considerations.

Failure to document that a patient meets trial‑like eligibility (primary diagnosis, baseline severity thresholds, prior therapy trials, and absence of excluded comorbidities) may increase risk of denial under prior authorization review.

The policy includes a dedicated section summarizing evidence for psychiatric and neurologic disorders other than depression, migraine, and OCD, and states those indications are handled separately in the document. For many of these conditions the evidence base is limited—trials are typically small, heterogeneous in stimulation parameters and targets, and lack durability data—so routine coverage is not supported in this excerpt.

Examples discussed elsewhere in the policy include bipolar disorder, generalized anxiety disorder, panic disorder, PTSD, schizophrenia, substance use/craving, ALS, chronic pain, epilepsy, fibromyalgia, Parkinson disease, and stroke recovery; for these conditions the policy highlights the need for larger, higher‑quality trials before routine coverage can be recommended.

The policy repeatedly notes evidence limitations that affect applicability and coverage decisions: many studies enrolled populations that are not fully representative of intended clinical populations, trial interventions and parameters were heterogeneous or poorly defined, and follow‑up durations were often short and insufficient to demonstrate durability of benefit.

These study‑level relevance limitations (population representativeness, intervention definition, outcomes measured, and insufficient follow‑up) are cited as reasons for cautious interpretation of positive short‑term findings and for requiring documentation that the proposed clinical use mirrors trial populations and protocols.

Systematic reviews and meta‑analyses for chronic pain and for amyotrophic lateral sclerosis (ALS) report only small, short‑term effects or identify trials of poor methodological quality. For chronic pain meta‑analysis, the pooled short‑term effect size was small (SMD ~‑0.22) and did not meet common minimum clinically important difference thresholds (e.g., <15% reduction in pain).

For ALS, Cochrane reviews found very limited RCT data of poor quality with high attrition and heterogeneity; reviewers concluded evidence is insufficient to determine efficacy or safety. Based on these summaries, the policy states routine coverage for chronic pain indications and ALS is not supported.

Across many non‑depression neurologic and psychiatric indications, the policy emphasizes there are no large, high‑quality trials demonstrating both efficacy and durability of rTMS effects. The document states these indications lack robust evidence and therefore are not supported for routine coverage in the current evidence base.

The policy recommends that requests for such indications include rigorous documentation and ideally enrollment in research protocols until larger definitive trials are available.

The American Academy of Child and Adolescent Psychiatry (2013) did not recommend rTMS for children and adolescents with tic disorders, citing limited evidence on safety, ethical concerns, and unknown long‑term developmental impact. The policy therefore reflects caution for pediatric use and references limited pediatric recommendations in guideline statements.

Policy history notes prior updates that added contraindications such as recent excessive use of alcohol or illicit substances and expanded acceptable providers (e.g., addition of Psychiatric Mental Health Nurse Practitioners). These historical entries are recorded in the policy history and inform current exclusion language and provider documentation requirements.

The policy states that rTMS for major depressive disorder that does not meet the specified coverage criteria (age ≥18, documented severe MDD on standardized scales, adequate prior medication and psychotherapy trials, absence of contraindications, and required documentation) is considered investigational and not medically necessary.

It further specifies that rTMS of the brain is investigational for other psychiatric/neurologic disorders (including but not limited to bipolar disorder, schizophrenia, OCD, and migraine) unless criteria for a covered indication are explicitly met.

FDA labeling cautions that certain migraine TMS devices have not demonstrated safety/effectiveness for cluster headache, chronic migraine, or when used during the aura phase; labeling also notes they have not been shown to relieve associated migraine symptoms. The policy echoes these regulatory cautions and advises that use outside labeled indications be considered with the regulatory evidence and possible denial risk in mind.

Thus, device‑specific regulatory limitations inform the policy stance that such migraine applications are not established as effective or safe per device labeling.

Where intention‑to‑treat (ITT) analyses fail to show significant benefit—or where effect sizes fall below prespecified clinically important thresholds—the policy notes those results as diminishing confidence in net clinical benefit. For example, the Brainsway deep TMS pivotal trial showed per‑protocol and modified‑ITT benefits but the full ITT analysis did not find a significant benefit at some time points; such analytic discrepancies inform the policy's cautious interpretation of efficacy.

Consequently, the policy may consider results that are significant only in per‑protocol or modified‑ITT analyses and not in ITT as insufficient to establish routine coverage without additional supportive data.

Evidence on rTMS effects for migraine‑associated symptoms (photophobia, phonophobia, nausea) is limited: FDA labeling for migraine devices states the device has not been demonstrated to relieve these associated symptoms, and pivotal trial analyses have not established consistent benefit for such outcomes.

The policy therefore notes limited support for rTMS in relieving associated migraine symptoms and that primary trial endpoints and post hoc analyses have constrained certainty.

The excerpt does not consistently use the explicit phrase 'not medically necessary' for every indication discussed; however, separate policy sections and summaries state investigational or not medically necessary stances for uses that do not meet prespecified criteria. Reviewers should reference the policy's investigational and not medically necessary statements elsewhere in the document for full determinations.

Where explicit 'not medically necessary' language is absent in the evidence excerpts, the document still documents investigational designations for off‑criteria uses (e.g., non‑TRD psychiatric/neurologic indications).

Systematic reviews and subsequent small randomized trials for schizophrenia provide equivocal and very low‑quality evidence. A Cochrane review concluded evidence was insufficient to support or refute TMS for schizophrenia; additional small, single‑center RCTs published later had high attrition and inadequate follow‑up, and do not provide adequate evidence to support routine use.

Thus, the policy states that evidence is insufficient to recommend routine rTMS for schizophrenia symptoms (including auditory hallucinations or negative symptoms) outside research settings.

Meta‑analyses for chronic pain indicate only small short‑term reductions in pain intensity that did not meet minimum clinically important difference thresholds; pooled estimates (SMD ~‑0.22) correspond to modest absolute changes that are unlikely to be clinically meaningful.

Because effect sizes are small and durability is uncertain, the policy identifies chronic pain rTMS evidence as insufficient to support routine clinical coverage.

The policy emphasizes that many non‑depression indications lack large, high‑quality randomized trials demonstrating efficacy or durability; small, heterogeneous trials predominate and stimulation parameters are not standardized across studies. As a result, the evidence does not support routine clinical use for many of these indications at this time.

Requests for such indications should include rigorous supporting documentation and are often considered investigational pending more definitive trials.

NICE guidance summarized in the policy states that while short‑term efficacy evidence for depression is adequate, evidence for OCD and auditory hallucinations is lacking and rTMS should be used for these conditions only in research contexts. NICE also noted limited and low‑quality evidence for migraine prevention and uncertainty about long‑term safety with frequent use.

The policy references NICE recommendations to support a research‑oriented approach for OCD and auditory hallucinations rather than routine clinical adoption.

Procedure and Diagnosis Codes

Codes table referencedmixed

No codes listed

FDA Product Codes referencedmixed

OBP	FDA product code for devices cleared for major depressive disorder
OKP	FDA product code for devices cleared for migraine headache pain
QCI	FDA product code for devices cleared for obsessive-compulsive disorder

Related procedural codes (examples)CPT

90867	Electroconvulsive therapy
90868	ECT subsequent
90869	ECT under anesthesia

Procedure CPT/Category III codesCPT | mixed

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; subsequent motor threshold re-determination with delivery and management, per session.
0889T	Personalized target development for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation derived from a structural and resting-state functional MRI, including data preparation and transmission, generation of the target, motor threshold - starting location, neuronavigation files and target report, review.
0890T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including target assessment, initial motor threshold determination, and interpretation.
0891T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, initial treatment day.
0892T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, subsequent treatment day.

Referenced ICD-10-CM diagnosis codesICD-10

F32.0-F32.9	Major depressive disorder, single episode, code range.
F33.0-F33.9	Major depressive disorder, recurrent, code range.

Acute phase treatment frequency

Acute phase frequencyNot to exceed 5 days/week for 6 weeks (total of 30 sessions) with a 3-week taper of 3, then 2, then 1 session

Taper scheduleWeek 1 post-acute: 3 sessions; Week 2: 2 sessions; Week 3: 1 session

Maximum authorized acute-course sessionsUp to 36 sessions when taper included (30 acute + 6 taper)

Stimulation intensity

Stimulation intensity range100% to 120% of motor threshold

Motor threshold determination

Prior Authorization, Documentation, and Step Therapy

Prior Authorization

Prior authorization: clinician documentation and diagnostic confirmation

Prior authorization requires legible clinical documentation from the recommending psychiatrist (MD/DO) or Psychiatric Mental Health Nurse Practitioner (PMHNP) who evaluated the patient in person. Documentation must include current symptoms, treatment history, rationale for rTMS, and confirmation of diagnosis by a standardized, validated depression rating scale with baseline and follow‑up assessments (before treatment and within 1–2 months after the acute phase). Authorization is contingent on meeting all listed coverage criteria (age ≥18, prior medication/augmentation trials or exceptions, adequate psychotherapy trial, and absence of contraindications).

Provider must be a psychiatrist (MD/DO) or PMHNP who evaluated the patient in person.
Include baseline and 1–2 month post-acute phase standardized depression rating scale scores.
Show prior medication/augmentation trials, psychotherapy trial documentation, and absence of listed contraindications.

Prior Authorization

Prior authorization guidance: FDA‑cleared devices and indications

The policy enumerates FDA‑cleared rTMS devices and their cleared indications; these device clearances and indications (e.g., devices cleared for major depressive disorder, migraine with aura, or OCD) may inform but do not replace insurer-specific prior authorization requirements. Providers should reference the device and indication in their authorization request when relevant.

Key Terms and Modalities

Deep rTMS

Deep rTMS coil typeUses an H-coil helmet design to stimulate deeper brain structures

Session durationTypically shorter session duration (~20 minutes) compared with conventional figure-8 coil rTMS (~40 minutes)

Broader stimulation areaH-coil intended to encompass a broader cortical surface area and reach deeper targets than conventional coils

Motor threshold definition

Motor threshold definitionMinimum intensity of stimulation required to induce a motor response, empirically determined per person

Determination methodLocalize scalp site for optimal hand-muscle response then increase stimulation intensity to identify threshold

Modalities, Variants, and Level-of-Care

inv-118: TMS — modality description and related clinical notes (1 top-level node)

Modality description: TMS modalities include conventional figure-8 coil rTMS (~40 minutes/session) and deep rTMS using an H-coil (~20 minutes/session); treatments should use FDA-cleared devices and be performed by trained psychiatrists or PMHNPs

inv-119: TMS — modality and parameters (1 top-level node)

Modality and parameters: Modalities and parameters should match those evaluated in trials or be FDA-cleared; stimulation intensity in trials was commonly 100%–120% of motor threshold and typical acute schedules were 5 days/week for 4–6 weeks or accelerated multiple sessions/day100%–120% motor threshold

inv-120: TMS — several modality-related nodes (4 top-level nodes)

Session Limits and Visit Parameters

Background and Evidence Context

Transcranial magnetic stimulation (TMS) is a noninvasive technique that delivers electromagnetic pulses via a scalp coil to modulate cortical activity. Repetitive TMS (rTMS) delivers repeated pulse trains to a targeted cortical area; deep rTMS uses an H‑coil to stimulate deeper structures; and theta burst stimulation is a patterned form of TMS delivering bursts at shorter intervals and lower intensity.

inv-13 (also used here): Evidence-informed coverage considerations summarized from multiple meta-analyses and systematic reviews

Evidence-informed summary: Multiple meta-analyses and systematic reviews across disorders provide effect-size estimates, heterogeneity assessments, and identify evidence gaps that inform coverage decisions; small trial sizes and protocol heterogeneity limit generalizability

For treatment‑resistant depression (TRD), the policy summarizes that multiple sham‑controlled RCTs and meta‑analyses show improved response and remission rates with conventional rTMS and theta‑burst stimulation compared with sham. The document concludes that evidence is sufficient to consider rTMS an option for TRD when patients meet defined clinical criteria (e.g., prior adequate medication and psychotherapy trials and documented severity).

The policy reiterates that evidence for chronic pain and ALS is limited and of low quality: chronic pain meta‑analyses found only small short‑term effects that did not reach clinically important thresholds, and ALS RCTs were few and poor quality, leaving insufficient evidence to support routine coverage for these indications.

Policy History and References

Literature update through Apr 9, 2026references_update

Reference list and literature search updated to include evidence through April 9, 2026 (references span approx. 13–85).

2026-02-26literature_update

Clarification added to policy; literature review updated (as noted) with changes adopted effective 02/26/2026.

2026-05-28literature_updateLatest

Policy Summary

PayerBluecross Idaho

PolicyRepetitive Transcranial Magnetic Stimulation (rTMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

Policy CodePolicy MP 3.01.550

Change TypeNo material changes

Effective DateMay 28, 2026

Last ReviewMay 28, 2026

Next Review DateMay 28, 2026

SourceLink

On This Page

Parkinson disease motor symptoms: Meta‑analyses found small‑to‑moderate effects on motor scales, with high‑frequency rTMS to primary motor cortex most effective in some reviews; trial sizes vary and results heterogeneous

Benefit depends on target and frequency

Routine coverage not supported based on current evidence

Empirically determined per patient by inducing a motor response over motor cortex

Trial convention noteUnless otherwise indicated, trials used 100%–120% of motor threshold

Number of rTMS sessions in trials

Conventional trial scheduleDelivered 5 times/week for 4–6 weeks (once-daily sessions)

Accelerated protocolsMultiple sessions per day (≥2 sessions/day) over shorter periods (1–3 weeks) in accelerated trials

Examples from studiesBlumberger et al: 5x/week for 4–6 weeks; Cole et al/SNT and Hanlon et al: multiple daily sessions in accelerated protocols

YBOCS response threshold

YBOCS response threshold≥35% improvement on Yale-Brown Obsessive Compulsive Scale predictive of treatment response

YBOCS scale rangeTotal score range 0–40; severity bands map to clinical severity

Outcome timing noteFollow-up over months is of interest to monitor durability of YBOCS improvement

Ferromagnetic material exclusion distance

Ferromagnetic material exclusion distance10 cm from the TMS coil (updated contraindication threshold)

Prior policy distance notePolicy previously referenced implanted magnetic-sensitive devices within 30 cm as contraindication; updated safety data support 10 cm

Example excluded itemsCochlear implants, pacemakers, ICDs, VNS, metal aneurysm clips/coils, staples, or stents — proximity to coil must respect exclusion distance

Table lists devices cleared for MDD (Product Code: OBP), migraine (OKP), and OCD (QCI).
FDA clearance does not obviate plan-specific authorization or benefit determination.

Prior Authorization

Prior authorization for rTMS: include prior treatment failures and protocol rationale

When requesting rTMS for treatment‑resistant depression (TRD), prior authorization should document prior treatment failures and the clinical rationale: specify number and classes of antidepressant trials and augmentation attempts (or documented intolerance), current medications, and the planned rTMS protocol (e.g., conventional, theta‑burst, accelerated).

Document inadequate response to ≥2 antidepressants from different classes and details of ≥2 augmentation trials OR documented intolerance to ≥2 antidepressants, or barriers to ECT.
Specify contemporaneous medication status and the rTMS protocol (modality and schedule).
Indicate how the patient meets TRD criteria used in trials (e.g., failed ≥2 adequate trials).

Prior Authorization

Prior authorization likely required: align requests with RCT/meta‑analysis context

Because coverage determinations are informed by randomized controlled trials and meta‑analyses showing benefit for some indications, prior authorization is likely required and should include evidence of prior therapies, response/remission status, and plans for maintenance or tapering when durability is a concern.

Provide documentation of prior treatments and outcome measures referenced in trials.
Include proposed maintenance/tapering strategy if applicable to demonstrate plans for durability of benefit.

Documentation Required

Prior authorization documentation: OCD‑specific expectations (YBOCS, CBT, SRI)

For OCD claims, prior authorization should include documentation that OCD is the primary diagnosis, baseline Yale‑Brown Obsessive Compulsive Scale (YBOCS) score (trial‑eligible baseline typically >20), and prior trials of cognitive behavioral therapy (CBT) and at least one adequate serotonin reuptake inhibitor (SRI) trial or maintenance SRI dosing ≥2 months.

State that OCD is the primary disorder and provide baseline YBOCS score.
Document prior CBT trial length, attendance, and response; document prior SRI trial(s) or maintenance dosing ≥2 months.
Show patient characteristics similar to pivotal trial populations (outpatient setting, YBOCS >20).

Documentation Required

Prior authorization documentation: target disorder, treatment history, and rationale

Prior authorization requests should document the target disorder, the specific rTMS intervention planned (modality, target, and parameters), prior and concurrent therapies (pharmacologic and behavioral), and intended outcome measures with follow‑up plans to allow assessment of similarity to studied populations and expected outcomes.

Specify disorder being treated and the rTMS modality (conventional, deep TMS, iTBS, accelerated) and stimulation parameters.
List prior or concurrent comparator therapies (antidepressants, psychotherapy, ECT) and planned outcome measures and follow‑up timing.

Prior Authorization

Prior authorization recommended: require robust documentation due to small/variable trials

Given many trials are small, single‑center, and have variable quality and attrition, the policy recommends robust prior authorization documentation showing indication, prior treatments tried, and clinical stability or refractoriness to support medical necessity determinations.

Provide trial‑level evidence or rationale when treating indications with limited or heterogenous data.
Include documentation addressing study limitations and how the patient aligns with trial populations.

Prior Authorization

Prior authorization: align requests with evidence strength

Prior authorization decisions should reflect the strength of the evidence: indications supported by moderate‑to‑high quality RCT evidence (for example, certain TRD protocols) may be treated differently than indications with low or insufficient evidence; document the evidence basis for the requested indication and protocol.

Cite relevant RCTs/meta‑analyses or guideline endorsements when applicable.
Clarify whether the planned protocol matches those evaluated in higher‑quality trials.

Prior Authorization

Prior authorization for evidence‑supported indications: ensure protocols match trial evidence

Prior authorization for indications supported by evidence (e.g., TRD) should ensure rTMS is used with protocols and parameters that match those evaluated in trials (conventional high‑frequency rTMS or iTBS, session frequency/duration consistent with studied schedules) and that prior therapy history meets policy criteria.

Confirm planned treatment course (e.g., up to 30 sessions over 4–6 weeks with taper to total ≤36) and stimulation intensity/parameters consistent with trial protocols.
Document prior antidepressant and augmentation trials per policy to support TRD indication.

Prior Authorization

Prior authorization implied: treatment course and insurer context

The policy context and recommended full treatment courses (30–36 sessions, typical daily schedules) imply that prior authorization will be required to determine coverage and to authorize a full acute treatment course; exact coding and authorization processes are plan‑specific.

Requests should reference the intended full treatment course (30–36 sessions) and schedule.
Contact the member’s plan for exact coding and prior authorization procedure.

Billing Rule

Prior authorization and listed codes: codes are reference only; coverage is benefit‑dependent

Procedure and Category III codes are listed in the policy for reference (e.g., CPT and Category III codes for TMS and accelerated, fMRI‑guided protocols), but inclusion of codes in the document does not guarantee coverage—coverage and any prior authorization requirements depend on the member’s specific benefit plan.

Codes are provided for general reference only; verify member benefit for coverage and reimbursement.
Follow member‑specific benefit plan and this medical policy when submitting claims.

Step Therapy

Medication and augmentation trials required before rTMS (unless exception documented)

Prior authorization for TRD requires documentation of prior adequate antidepressant trials: specifically, at least 2 antidepressant agents from different classes and adequate augmentation trials (each adequate trial defined as ≥6 weeks at maximally tolerated/clinically effective dose), unless there is documented intolerance or a contraindication.

An adequate antidepressant or augmentation trial is ≥6 weeks with dose titration to maximally tolerated and clinically effective dose.
Document intolerance or contraindication if the usual medication/augmentation trials were not completed.

Step Therapy

Treatment sequencing: rTMS considered after pharmacotherapy/psychotherapy (and sometimes ECT)

rTMS is considered relative to pharmacotherapy, psychotherapy, and ECT; stepwise sequencing or step‑therapy may apply such that rTMS is typically considered after inadequate response to standard therapies (pharmacologic and behavioral) and, in some guidance, after failure of ≥2 adequate pharmacologic trials.

Document prior use and outcomes of pharmacotherapy and psychotherapy and consider ECT barriers if relevant.
Align sequencing rationale with guideline context and trial eligibility where applicable.

Step Therapy

Step therapy for TRD: document failure of multiple antidepressant trials (commonly ≥2)

Clinical trial contexts and guideline recommendations commonly required failure of multiple antidepressant trials (for example, ≥2) before labeling patients as treatment‑resistant and considering rTMS augmentation or switch strategies; prior authorization should document these prior antidepressant failures per policy definitions.

Trials often excluded patients who had failed >3 adequate trials—document how the patient’s treatment history aligns with trial criteria.
State the number and classes of failed antidepressant trials and adequacy per policy (≥6 weeks at effective dose).

Step Therapy

Step therapy considerations: review prior use of established therapies for migraine and OCD

For migraine and OCD, prior use of standard therapies should be documented and will be reviewed as part of authorization given the evidence summaries reference prior pharmacologic and behavioral therapy use in trial populations.

For migraine, document prior pharmacologic therapies and baseline headache frequency/severity.
For OCD, document prior CBT and SRI trials as described in pivotal trials.

Step Therapy

Step therapy considerations: prior CBT and SRI trials referenced in evidence

Evidence summaries for OCD reference prior CBT and SRI trials as background eligibility in key RCTs; prior authorization and step‑therapy expectations should reflect prior adequate CBT and at least one adequate SRI trial unless documented contraindication exists.

Carmi et al (2019) required CBT failure and SRI treatment or maintenance SRI dosing ≥2 months prior to randomization.
Document psychotherapy trial details and SRI trial duration/dosing in authorization requests.

Step Therapy

Step therapy expectations: document prior pharmacologic and behavioral comparators

Comparators in practice and in trials include pharmacotherapy and psychological/behavioral therapy for psychiatric disorders and pharmacotherapy plus therapy for neurologic disorders; prior authorization expectations should reflect that rTMS is typically considered after standard therapies have been tried.

List prior pharmacologic and behavioral therapies and their outcomes in the authorization request.
Indicate why rTMS is being chosen over or added to comparator therapies.

Step Therapy

Step therapy not specified in policy excerpt: document treatment‑resistance and trial alignment

The document does not specify explicit step therapy rules; many trial contexts involved treatment‑resistant populations, so authorization should document prior treatments and how the patient matches trial‑like inclusion criteria.

If step therapy rules exist in the member’s plan, follow those plan‑specific rules.
Provide treatment history to demonstrate alignment with trial eligibility when explicit step rules are not present.

Step Therapy

Step therapy not addressed in sections: use trial/guideline context

Parts of the document do not address specific step therapy algorithms; where not specified, requests should rely on trial‑based eligibility and guideline context to justify rTMS placement in the treatment sequence.

When no explicit step therapy rule is provided, describe prior treatment history and clinical justification for rTMS.
Reference guideline recommendations (e.g., VA/DoD, NNDC) when applicable.

Step Therapy

Step therapy context for TRD: rTMS as option after inadequate antidepressant response

Evidence and guidance emphasize rTMS as an option for treatment‑resistant depression after inadequate response to antidepressant medications; prior authorization should document inadequate response to pharmacotherapy consistent with TRD definitions used in trials and guidelines.

Document number and adequacy of prior antidepressant trials; reference guideline‑based definitions when applicable.
State whether rTMS is being requested as augmentation, switch, or replacement therapy.

Note

Step therapy guideline: VA/DoD recommends rTMS after ≥2 failed pharmacologic trials

VA/DoD guidance recommends offering rTMS after inadequate response to two or more adequate pharmacologic treatments (weak recommendation); prior authorization requests may reference this guidance when documenting prior medication failures.

State prior pharmacologic trials (number, agents, adequacy) to align with VA/DoD context.
Note that the VA/DoD recommendation is graded as a weak recommendation with limited evidence confidence.

Documentation Required

Required clinical documentation: legible clinician and therapist records, rating scales, rationale

Legible clinical documentation from the recommending psychiatrist (MD/DO) or PMHNP must accompany requests and include current symptoms, treatment history, rationale for rTMS, and depression rating scale scores before and within 1–2 months after the acute phase; therapist documentation should detail psychotherapy length, attendance, and progress.

Include therapist’s written documentation of psychotherapy trial length, attendance, progress, and type of evidence‑based therapy.
Provide clinician‑recorded baseline and follow‑up depression rating scale scores.

Documentation Required

Clinical measurement and treatment parameter documentation required

Authorization documentation should include baseline and follow‑up depression severity measures (e.g., HAM‑D or MADRS) and detailed stimulation parameters used in treatment such as motor threshold percent, pulse trains, total pulses, and number of sessions.

Provide motor threshold percentage (typical trials used 100%–120% of motor threshold).
State total pulses, pulse trains, and planned number of sessions and schedule.

Documentation Required

Required supporting clinical documentation: trial reports, response/remission, follow‑up

Supporting clinical documentation may include randomized trial reports (per‑protocol and ITT analyses), published response and remission rates, and available maintenance or follow‑up data to contextualize expected benefit and durability for the requested intervention.

Attach or cite key RCTs or meta‑analyses relevant to the requested modality when seeking authorization for nonstandard protocols.
Provide any available follow‑up outcome data for the individual patient.

Documentation Required

Migraine‑specific documentation: baseline frequency/severity and timing relative to aura

For migraine claims, prior authorization should include trial‑level details relevant to pivotal migraine studies: baseline migraine frequency and severity, timing of treatment relative to aura, pain severity scores at prespecified post‑treatment intervals, associated symptom assessments, and rescue medication use.

Report baseline migraine days/frequency and pain severity.
Document timing of device use relative to aura and post‑treatment pain/symptom recordings at 1, 2, 24, and 48 hours as in pivotal trials.

Documentation Required

Prior authorization documentation: OCD primary diagnosis, YBOCS >20, prior CBT and SRI

For OCD authorization requests, include documentation that OCD is the primary diagnosis, baseline YBOCS score (trial‑eligible baseline typically >20), prior CBT trial details, and at least one adequate SRI trial or maintenance SRI dosing ≥2 months, consistent with pivotal trial eligibility.

Provide baseline YBOCS score and document CBT trial length, attendance, and response.
Document SRI trial(s) duration, dosing, or maintenance SRI status for ≥2 months prior to request.

Documentation Required

Follow‑up documentation: months of follow‑up and outcome measures desirable

Follow‑up documentation over months is desirable to monitor outcomes and durability; prior authorization and continued‑stay review should include planned follow‑up timing and measures used to assess clinical response.

Indicate planned timing for outcome reassessment (e.g., within 1–2 months after acute phase) and longer‑term follow‑up when available.
Provide intended clinical measures to be used for follow‑up (HAM‑D, MADRS, YBOCS, pain scores as relevant).

Documentation Required

Documentation to address evidence gaps: relevance and design limitations

To address evidence gaps noted in trials, authorization documentation should explain how the patient and proposed intervention align with studied populations and interventions (population representativeness, intervention definition, outcomes, and follow‑up), including any differences and rationale for generalizability.

Describe how the patient’s characteristics match or differ from trial populations and why the intervention is expected to be effective.
Address any limitations in evidence and provide clinical justification if deviating from trial protocols.

Documentation Required

Evidence summary documentation: cite systematic reviews/meta‑analyses and protocol details

When requesting rTMS for indications supported by meta‑analyses or systematic reviews (e.g., substance use, neuropathic pain), include evidence summary details such as targeted brain region, stimulation frequency, number of sessions, and measured outcomes to support the clinical rationale.

Cite relevant systematic reviews/meta‑analyses and summarize the protocol elements that match the proposed treatment.
Provide expected outcome measures and timelines consistent with the evidence cited.

Documentation Required

Documentation to support TRD: reflect TRD diagnosis and prior therapy history

To support a TRD diagnosis for authorization, ensure records reflect treatment‑resistant depression criteria and prior therapy history (number and adequacy of antidepressant and augmentation trials, psychotherapy trial), as policy and evidence emphasize TRD populations in determining rTMS medical necessity.

Document adequacy of prior antidepressant and augmentation trials per policy definition (≥6 weeks at effective dose).
Include psychotherapy trial documentation and clinician rationale for TRD classification.

Documentation Required

Operational documentation: environment, operator qualifications, coil/target, motor threshold, session counts

Operational documentation should describe the clinical environment, operator qualifications, coil and target selection, method for motor threshold determination, and planned number of treatment sessions to demonstrate appropriate delivery conditions.

State operator qualifications and treatment setting, coil type and cortical target, and method used to determine motor threshold.
Include planned session count and schedule and any neuronavigation or imaging guidance to be used.

Billing Rule

Coding and documentation guidance: codes are reference; follow member benefit plan

Coding guidance in the policy is provided for reference, but the inclusion of codes does not guarantee coverage; providers must follow member‑specific benefit plan documentation and the written coverage position when submitting prior authorization and claims.

Verify member coverage and any plan‑specific prior authorization procedures before billing.
Use codes as a reference while following plan rules for coverage determinations.

Denial Risk

Denial risk: insufficient or illegible clinical documentation may lead to denial

Requests lacking legible clinical documentation from the treating psychiatrist (MD/DO) or PMHNP—including current symptoms, treatment history, rationale for rTMS, standardized depression rating scale results, or documentation of prior medication and psychotherapy trials—may be denied.

Ensure all documentation is legible and authored by the treating psychiatrist or PMHNP who evaluated the patient in person.
Include explicit rating scale scores, dates of prior trials, and therapist documentation to avoid denial for insufficient documentation.

Denial Risk

Denial risk: regulatory contraindications or off‑label device use may affect coverage

Using devices outside their intended FDA‑cleared populations (for example, certain migraine devices not cleared for pregnant women, children <18, or adults >65, or use during aura for some devices) or for contraindicated headache types may trigger denial; cite the device labeling and restrict use to cleared indications unless compelling justification is provided.

Reference device‑specific intended use (e.g., Cerena intended for migraine with aura onset) when requesting coverage.
Document clinical justification when proposing off‑label device use; expect additional review or potential denial.

Denial Risk

Denial risk: evidence limitations (variable effect size, limited durability) may affect coverage

Evidence limitations—variable effect sizes, outcomes smaller than some prespecified clinically important differences, and lack of durable benefit in some intent‑to‑treat analyses—may support denial or additional review when the request lacks evidence the patient will derive meaningful or durable benefit.

Provide objective measures of expected benefit and durability consistent with trial evidence.
Explain why the patient is likely to achieve clinically meaningful benefit despite trial heterogeneity or limited durability data.

Denial Risk

Denial risk: pivotal migraine trial limitations (dropout, post‑hoc analyses) may prompt denial or additional review

High dropout rates and reliance on post‑hoc analyses in pivotal migraine trials (e.g., Cerena) may limit certainty of benefit; authorization for migraine indications may be subject to additional scrutiny or denial if trial‑like eligibility and outcome documentation are not provided.

Document how the patient aligns with pivotal trial eligibility (e.g., aura frequency as in Cerena trial) and provide baseline/post‑treatment outcome measures.
Expect increased review when pivotal trial limitations (high dropout/post‑hoc analyses) apply to the requested indication.

Denial Risk

Denial risk: not meeting trial‑based eligibility (e.g., YBOCS >20, failed CBT/SRI) may lead to denial

Failure to meet strict trial‑based eligibility (for example, Carmi et al required adults with primary OCD and YBOCS >20 and prior CBT and at least one adequate SRI trial) may result in denial if similar criteria are applied for coverage; ensure authorization documentation demonstrates eligibility comparable to pivotal trials when those trial criteria inform policy application.

Provide baseline YBOCS score and prior CBT/SRI trial documentation for OCD requests.
State how the patient meets key trial inclusion criteria if those criteria are being used to assess coverage.

Denial Risk

Denial risk: duplicate/overlapping prior authorization requests may be denied

Duplicate or overlapping prior authorization requests referencing the same study populations or prior course of treatment may be denied; ensure documentation distinguishes the present request and avoids duplicative submission of identical prior authorization justifications.

Clarify whether the request is for an initial acute course, retreatment, or maintenance and document timing relative to any prior TMS courses.
Avoid submitting duplicate authorizations for the same treatment period or indication.

Denial Risk

Denial risk: study limitations (small samples, attrition, short follow‑up) may prompt noncoverage

Small sample sizes, high loss to follow‑up, inadequate follow‑up duration, and other study limitations cited in the evidence (Tables 14–15) may lead to determinations that evidence is insufficient for certain indications and result in denial for those indications without stronger supporting data.

Provide longer‑term follow‑up data or stronger evidence when requesting authorization for indications with limited study quality or short follow‑up.
Address study design limitations in the request and explain relevance to the patient.

Denial Risk

Denial risk: limited effectiveness for chronic pain may lead to denial

Evidence for chronic pain and neuropathic pain shows only small short‑term effects that did not meet minimum clinically important difference thresholds in some reviews; routine coverage for chronic pain indications may be denied based on these evidence limitations.

For chronic pain requests, provide compelling evidence the patient aligns with positive subgroups or trial designs.
Expect denials for routine chronic pain indications absent stronger, applicable evidence.

Denial Risk

Denial risk: insufficient evidence for ALS indicates likely noncoverage

For ALS and similar indications, reviewers concluded evidence is insufficient to determine efficacy or safety; prior authorization is unlikely to be approved for routine use for ALS without substantially stronger trial evidence.

Provide high‑quality trial data if requesting rTMS for ALS; otherwise expect noncoverage.
Document rationale and any investigational context if seeking approval.

Denial Risk

Denial risk: insufficient evidence for other indications may lead to denial

Use of rTMS for psychiatric or neurologic disorders other than depression, migraine, or OCD is not supported by large, high‑quality trials; requests for these indications should include strong supporting evidence or may be denied as investigational.

List and attach relevant RCTs or meta‑analyses when requesting rTMS for non‑supported indications.
Expect denials when evidence is limited, heterogeneous, or of low quality.

Denial Risk

Denial risk: safety deviations (ferromagnetic material exclusion distance) may affect coverage

Failure to respect updated safety recommendations—for example, the updated contraindication distance for ferromagnetic material near the TMS coil (revised from 30 cm to 10 cm)—could raise safety or coverage concerns and should be addressed in documentation of contraindications and treatment planning.

Document absence of ferromagnetic material within the updated 10‑cm exclusion zone when relevant.
Address any deviations from updated safety guidance and provide clinical justification.

Billing Rule

Coverage is benefit‑dependent: codes in the policy do not ensure coverage or reimbursement

Inclusion of procedure and Category III codes in this policy is for reference only; presence of a code does not guarantee member coverage or provider reimbursement—benefit determinations and any prior authorization requirements are determined by the member’s specific benefit plan and this written policy.

Verify member benefits before billing; code lists in the policy are not a coverage guarantee.
Follow the member’s plan rules and prior authorization procedures.

Use in dosingStimulation intensity in trials is expressed as percent of individual motor threshold

Deep TMS (H-coil helmet)

H-coil helmet designH-coil helmet enables stimulation of a broader surface area and deeper brain structures than conventional figure-8 coils

Evidence contextDeep TMS pivotal RCTs (e.g., for OCD and depression) used H-coil devices as the basis for FDA clearance considerations

Session duration comparisonDeep TMS sessions are generally shorter (~20 minutes) versus conventional TMS (~40 minutes)

Theta burst stimulation

TBS protocol characteristicsAdministered at lower intensities and shorter intervals than conventional rTMS (patterned bursts)

iTBS noninferiorityIntermittent TBS (iTBS) shown noninferior to 10-Hz rTMS in a large multicenter noninferiority trial (Blumberger et al 2018)

Treatment duration advantageiTBS sessions are much shorter (minutes) compared with conventional rTMS (tens of minutes)

Clinical response and remission conventions

Clinical response conventionResponse commonly defined as ≥50% improvement on HAM-D in trials

Remission conventionRemission often considered HAM-D score ≤7 in referenced trials

Use in retreatment criteriaPrior positive rTMS response for retreatment is defined as ≥50% reduction on same rating scale

TBS / iTBS

TBS/iTBS descriptionPatterned burst stimulation delivering intermittent theta-burst sequences; used as brief sessions with lower intensity

Efficacy comparisoniTBS demonstrated noninferiority to conventional 10-Hz rTMS in a large trial (Blumberger et al 2018)

Practical advantageiTBS offers much shorter treatment time per session compared with standard rTMS

Deep TMS evidence and regulatory context

Deep TMS modality noteCoil-based modality (H-coil) with pivotal randomized trials supporting FDA clearance in some indications

Evidence nuancesPivotal RCTs for deep TMS showed per-protocol or modified-ITT benefits with mixed ITT findings and limited long-term durability in some analyses

Regulatory outcomeDeep TMS (Brainsway H-coil) received FDA de novo/510(k) classification for OCD and earlier clearances for depression

Accelerated / Stanford Neuromodulation Therapy (SNT)

Accelerated / SNT definitionHigh-dose accelerated iTBS protocols delivering multiple daily sessions (e.g., 5–10 sessions/day) over several days, sometimes fMRI-guided

Trial evidenceSmall RCTs (e.g., Cole et al 2022 SNT) and larger accelerated trials (e.g., Hanlon et al 2026) report substantial short-term effects but limited long-term durability data

Targeting methodsSome protocols use fMRI-guided individualized targeting; benefit of imaging-guided targeting over standard placement remains uncertain

Y-BOCS and OCD severity

Y-BOCS scale description10-item clinician-rated scale (each 0–4) with total range 0–40 used to assess OCD severity

Severity bands0–13 mild; 14–25 moderate; 26–34 moderate-severe; 35–40 severe

Use in trialsYBOCS used as primary outcome in OCD trials; improvement thresholds (e.g., ≥35%) predict response

YBOCS description

YBOCS description10 items scored 0–4 (total 0–40); maps to severity bands and used as clinician-rated outcome measure

Predictive improvement thresholdAn improvement ≥35% on YBOCS is most predictive of treatment response

Outcome monitoringFollow-up over months recommended to assess durability of effect

Accelerated TMS

Accelerated TMS definitionTwo or more sessions per day over 1–3 weeks (≥2 sessions/day), used in trials of OCD and TRD

Meta-analysis findingsMeta-analysis of 6 RCTs (N=150) found accelerated TMS significantly reduced OCD symptoms vs sham (SMD 0.63)

Durability caveatBenefits from accelerated protocols often not sustained at 2–8 week follow-up assessments

Deep TMS trials and key distinctions

Deep TMS pivotal trialsDeep TMS evaluated in sham-controlled RCTs (e.g., Carmi et al 2019) that informed FDA clearance; primary ITT results were mixed in some analyses

Modified ITT noteSome trials reported modified-ITT analyses (e.g., n=94 of 99) showing benefit while full ITT analyses were not statistically significant

Durability and secondary outcomesSecondary and patient-reported outcomes (disability) showed mixed results; further trials needed for durability evidence

Accelerated / SNT protocol features

Accelerated TMS dosingMultiple daily sessions (e.g., 10/day in SNT; 5/day in other protocols) delivering high cumulative pulses over days

fMRI-guided targetingSome protocols (SNT) use resting-state fMRI to individualize DLPFC targets; incremental benefit of guidance unclear

Short-term efficacyTrials show large short-term symptom reductions (high response/remission rates) though long-term durability remains uncertain

Y-BOCS / YBOCS scale details

YBOCS scoring and use10-item clinician-rated scale; total 0–40; used as primary outcome in OCD trials

Severity mappingScores 0–13 mild, 14–25 moderate, 26–34 moderate-severe, 35–40 severe

Response threshold relevancePolicy notes ≥35% improvement most predictive of treatment response

Recommended full treatment course and maintenance

Recommended full acute treatment course30–36 sessions (30 sessions over up to 6 weeks plus optional 6-session taper) per consensus guidance

Session frequency guidanceTypically administered up to 5 days/week during acute course

Maintenance TMS noteMaintenance/relapse-prevention strategies exist but optimal frequency/duration are unclear; evidence described as promising

rTMS safety findings

rTMS safety signalsActive rTMS associated with higher rates of headache, scalp pain, dizziness, facial twitching, and nausea versus sham; seizure prevalence low (≈1.39/1000)

No cognitive harm signalNo consistent evidence of increased cognitive impairment or worsening psychosis across reviewed studies

Adverse event monitoringHeadache and site pain are common treatment-related adverse events; serious events rare

Conventional high-frequency rTMS: Protocols delivered once daily, 5 days/week for 4–6 weeks have demonstrated benefit versus sham in meta-analyses

Intermittent theta-burst stimulation (iTBS): iTBS has been shown noninferior to 10-Hz rTMS in a large noninferiority trial and is an accepted initial protocol

Deep TMS (H-coil) has pivotal trials showing per-protocol benefits though ITT findings were mixed in some reports

Accelerated/High-dose iTBS (SNT): Accelerated high-dose iTBS protocols (SNT) have shown large short-term effects in small sham-controlled trials; durability and generalizability remain uncertain

inv-121: TMS — modality evidence node (migraine/OCD contexts)

rTMS modality note: rTMS, theta-burst stimulation, and accelerated protocols vary in evidence strength by indication; modality effectiveness depends on protocol, target, and indication

Clinical use should reference protocol type and trial evidence

inv-122: TMS — accelerated protocols evidence (1 top-level node)

Accelerated protocols evidence: Small sham-controlled RCTs of fMRI-guided SNT accelerated iTBS reported high response and remission rates at short-term follow-up, but studies were small, single-center, and lacked long-term durability data

inv-123: TMS — modality evidence node (1 top-level node)

rTMS modality evidence: Meta-analyses of multiple sham-controlled RCTs support efficacy of conventional rTMS and theta-burst stimulation for TRD; head-to-head data support noninferiority of iTBS

inv-124: rTMS — modality evidence node

rTMS safety evidence: Safety meta-analyses report higher rates of transient adverse events (headache, scalp pain, dizziness) with active rTMS versus sham; seizure prevalence is low (≈1.39 per 1000) and not different from sham

inv-125: TMS — modality-related evidence node (1 top-level node)

Substance use evidence: Meta-analyses of trials targeting DLPFC report medium effect sizes for reductions in craving, but included studies are small and heterogeneous; additional larger trials needed

inv-126: TMS variants — includes multiple variant nodes (3 top-level nodes)

Conventional TMS: Evidence from sham-controlled RCTs and meta-analyses shows improved response and remission rates in TRD; adverse events generally minimal compared with ECT

Included as treatment option for TRD

inv-127: TMS — modality node referencing guidelines/consensus

Recommended protocols: Consensus groups (NNDC/Clinical TMS Society) recommend full treatment courses of 30–36 sessions and consider iTBS or high-frequency rTMS appropriate initial protocols; maintenance evidence is promising but frequency is unclear30-36 sessions

inv-128: TMS — final modality/evidence node encompassing references

Modalities referenced in literature: rTMS (including deep TMS, theta-burst stimulation, and accelerated protocols) and device-specific systems (Brainsway, Cerena, NeuroStar, Cerena/SpringTMS variants) are discussed across references informing evidence and regulatory status

Across many non‑depression indications (bipolar disorder, PTSD, schizophrenia, substance use, Parkinson disease, stroke recovery, etc.), the policy notes a lack of large, high‑quality randomized trials demonstrating efficacy or durability, and therefore evidence is overall insufficient to support coverage for these conditions.

Professional guidance summaries cited include the American Psychiatric Association and NNDC/Clinical TMS Society recommendations supporting rTMS and iTBS as treatment options for TRD (with recommended full courses of about 30–36 sessions), VA/DoD suggestions to offer rTMS after inadequate response to ≥2 pharmacologic treatments, and NICE recommendations limiting routine use of rTMS for OCD and auditory hallucinations to research contexts.

Reference list and literature search updated and finalized for this policy version effective 05/28/2026; references section lists sources (refs ~13–85).

2021-10-28policy_replacement

Policy replaced and adopted by Blue Cross of Idaho; literature review through September 3, 2021 and references added.

2022-10-27policy_replacement

Policy replaced; effective 01/30/2023 — clarified documentation for severe MDD, added initial stepwise treatment criteria, psychotherapy duration, TMS remapping, subsequent retreatment criteria, and a contraindication for recent excessive substance use; literature review through August 19, 2022.

2023-10-26policy_replacement

Policy replaced; literature review through August 18, 2023 (references updated); policy statements unchanged.

2024-10-31policy_replacement

Policy replaced; literature review through August 12, 2024 with references added; policy statements unchanged.

2025-09-25policy_replacement

Policy replaced; effective 01/01/2026 — policy statements updated to include Psychiatric Mental Health Nurse Practitioners (PMHNP) as acceptable providers for rTMS.

2026-02-26policy_replacement

Policy replaced; effective 02/26/2026 — clarification added that PMHNPs may assess members for subsequent retreatment with rTMS; intent unchanged.

2026-05-28policy_replacementLatest

Policy replaced and adopted by Blue Cross of Idaho effective 05/28/2026; current consolidated policy version with updated effective and review dates.