Transcranial Magnetic Stimulation (TMS) Initiation Request
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Form and requirements for requesting prior authorization for initiation of Transcranial Magnetic Stimulation (TMS) for behavioral health patients served by Bluecross Idaho; applies to providers submitting authorization requests.
No material clinical or coverage changes in this revision.
Coverage Criteria for TMS Initiation
Initial TMS initiation coverage criteria
Covered when ALL of the following are documented on the form and in submitted medical records
Form includes tables to capture medication, augmentation, and psychotherapy trials
Rating scales and ECT history requested on form
Form includes checklist of contraindications
The form includes a contraindication checklist that must be completed. Documented contraindications include implanted stimulators (for example, a vagus nerve stimulator) and any ferromagnetic or other magnetic‑sensitive metals implanted or embedded in the head or neck within 11.8 inches of the TMS coil placement. Other listed contraindications include acute or chronic psychotic disorder, seizure disorder or history of seizures, active substance abuse at the time of treatment, and history of or current dementia. These conditions are identified on the form as reasons that may preclude TMS and should be explicitly addressed in the submitted medical records.
Prior authorization requests must include the completed form plus supporting medical records. Requests that do not document required treatment history (failed antidepressant medication trials, medication augmentation trials, psychotherapy trials of ≥4 months), standardized depression rating scale scores and dates, prior ECT history, and explicit screening for contraindications may be considered incomplete and can result in delay or denial. Missing data on the form or submission by fax/phone alone does not constitute authorization; ensure all supporting records are faxed as instructed.
Procedure Codes
Provider Actions and Submission Requirements
Prior authorization required for TMS initiation (specify CPT codes and session counts)
Request prior authorization for initiation of TMS services and specify the requested authorization date range and number of sessions for each CPT code listed on the form (90867, 90868, 90869). If more than one unit of 90869 is requested, explain the clinical reason on the form.
Provide required prior treatment documentation (meds, augmentation, psychotherapy)
Document prior treatment history on the form: failed antidepressant medication trials and failed medication augmentation trials (both with a preferred look-back of the last 5 years), and psychotherapy trials with most recent trials of 4 months or greater, to support medical necessity.
- List failed antidepressant medication trials with start/stop dates, doses, response, and intolerable side effects.
- List failed augmentation trials with start/stop dates, doses, response, and intolerable side effects.
- Document psychotherapy trials (therapist, credentials, start/stop dates, frequency, type) of ≥4 months.
Submit completed form with required supporting medical records by fax
Fax the completed TMS initiation form together with supporting medical records that document clinical indications and medical necessity, including failed antidepressant medication trials, augmentation trials, psychotherapy trials (≥4 months), standardized depression rating scale scores, prior ECT history and contraindication screening.
- Include standardized and validated depression rating scale pre- and post- scores and dates.
- List any prior ECT series with dates, locations, and outcomes; indicate whether the patient is an ECT candidate.
- Ensure the contraindications checklist from the form is completed and included in records.
Missing form data may delay prior authorization
Complete all requested fields on the form; missing data may result in an authorization delay.
- All information requested on the form must be complete.
- Submit elective prior authorization requests at least 10 days before the scheduled date of service when possible.
Fax/phone submission does not equal authorization; complete records required
Understand that submitting the completed form by fax or phone does not itself constitute authorization; Blue Cross of Idaho will notify you of the decision by secure email, mail, phone or fax, and lack of completed supporting medical records may prevent authorization.
- Submission via fax or phone is not authorization—await official notification from Blue Cross of Idaho.
- If medical necessity documentation is incomplete or contraindications are present, authorization may be denied or not issued.
Background
This form is used to document clinical indications and prior treatment failures to support prior authorization for initiation of Transcranial Magnetic Stimulation (TMS) for behavioral health indications. Complete the form in full, provide the requested authorization date range and service details, and fax the form with medical records to the Behavioral Health fax number listed; incomplete forms or missing documentation may delay the authorization decision.
Contraindications and Definitions
Treatment Modalities
TMS
Form fields request service details including frequency, authorization date range, and session counts.
Authorization Period and Visit Limits
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