Transcranial Magnetic Stimulation (TMS) Retreatment Request
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Governs prior authorization submission requirements for transcranial magnetic stimulation (TMS) retreatment requests for Bluecross Idaho members; affects ordering providers, facilities, and reviewers processing TMS authorizations.
No material clinical or coverage changes in this revision.
Coverage Criteria and Exclusions
Form Submission and Medical Necessity Requirements
Authorization considered when ALL of the following information is provided and supports medical necessity:
See chunks 0 and 2 for submission contacts, expedited attestation language, and authorization period.
Requested CPT codes captured on form: 90867, 90868, 90869 (see coding group).
See chunk 2 for required prior TMS and ECT fields.
See chunk 2 for the explicit contraindication checklist.
The form requires the provider to screen for and document the presence or absence of specific contraindications before TMS retreatment. Contraindications listed on the form include: vagus nerve stimulator or other implanted stimulators; ferromagnetic or other magnetic‑sensitive metals implanted or embedded in the head or neck within 11.8 inches of the TMS coil; acute or chronic psychotic disorder; seizure disorder or history of seizures; active substance abuse at the time of treatment; history of, or current, dementia diagnosis; and non‑adherence to previous treatment for depression.
The form does not itself state explicit "not medically necessary" (NMN) language. All determinations of medical necessity and authorization decisions are made by Blue Cross of Idaho's Healthcare Operations reviewers after review of the completed form and supporting medical records; the department will notify providers of their decision by secure email, mail, phone or fax.
Requested CPT Codes
Provider Submission Requirements and Actions
Prior authorization required — use TMS Retreatment Request form and allow ≥10 days
Prior authorization is required for TMS retreatment using the Blue Cross of Idaho TMS Retreatment Request form. Submit elective prior authorization requests at least 10 days prior to the scheduled date of service; submission by fax or phone does not constitute authorization and the Healthcare Operations department will notify you of the decision. Authorization periods may not exceed three months without review of medical records; include an explanation if special handling is justified.
- Use the TMS Retreatment Request form for all TMS retreatment prior authorizations.
- Submit elective requests ≥ 10 days before the scheduled date of service.
- Fax/phone submission alone does not equal authorization; wait for Healthcare Operations notification.
- Authorization period may not exceed three months without medical record review.
Document prior TMS and ECT series and outcomes to justify retreatment
The form requires documentation of prior TMS series (dates, provider, rating scale used with pre/post scores) and any prior ECT series and outcomes to justify retreatment; this information is used to assess medical necessity for the requested retreatment.
- Indicate whether previous TMS series were performed and provide date last series completed.
- List previous TMS series provider, date range, rating scale used, and pre/post scores with dates.
- List prior ECT series (date, location) and outcomes (number of successful treatments completed).
Fax completed form with supporting medical records and prior TMS details
Fax the completed TMS Retreatment Request form along with supporting medical records that document the clinical indications or medical necessity, including prior TMS series details, rating scale scores, prior ECT history/outcomes, and contraindication screening.
- Include medical records documenting clinical indications/medical necessity with the faxed form.
- Provide prior TMS series detail and pre/post rating scale scores.
- Include prior ECT history and outcomes and completed contraindication screening on the submission.
Missing or incomplete form data may delay or deny authorization
All information requested on the form must be complete; missing data may result in an authorization delay (or denial).
- Incomplete or missing data on the form can delay or prevent authorization.
- Ensure contraindication screening and prior treatment fields are fully completed before faxing.
Background and Purpose
This form is used to request prior authorization for Transcranial Magnetic Stimulation (TMS) retreatment. It collects the clinical rationale for retreatment, prior TMS series details (including dates, provider, rating scales and pre/post scores), prior ECT history and outcomes, and a formal contraindication screen. The completed form must be faxed with supporting medical records and submitted at least 10 days before elective service; missing data may result in authorization delay. Authorization periods may not exceed three months without review of medical records, and expedited requests require a signed attestation when delay could seriously jeopardize the member's life, health, or function.
Key Definitions and Contraindications
TMS Treatment Modalities
Transcranial Magnetic Stimulation (TMS)
See chunks 0 and 2.
Authorization Period and Visit Limits
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