CurrentCapital BluecrossPolicy BH-159 (05/27/25)

Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form and Clinical Criteria

This document is a preauthorization request form and clinical criteria checklist governing rTMS treatment requests for Capital Blue Cross members, used by providers to document diagnosis, prior treatments, and medical necessity for coverage decisions.

Policy Summary

PayerCapital Bluecross

PolicyRepetitive Transcranial Magnetic Stimulation (rTMS) Request Form and Clinical Criteria

Policy CodePolicy BH-159 (05/27/25)

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the completed rTMS request form with member/provider details, confirmed diagnosis (F32.2 or F33.2), pre‑treatment rating scale scores, detailed prior medication trials, and requested CPT code(s) for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2+min antidepressant trials

4alternate threshold

90867-90869CPT codes

717.346.5800fax

800.471.2242

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Coverage Criteria for rTMS

Capital clinical vignette Criteria for medical necessity

Alternate Capital clinical vignette criteria — any ONE of the following may support medical necessity:

Clinical vignette alternate criteria: Resistance to treatment with pharmacological agents as evidenced by lack of response to four trials from two agent classes OR lack of response to three trials from two agent classes plus one augmenting agent OR inability to tolerate pharmacological agents as evidenced by trials of four such agents with distinct side effects OR history of positive response to prior TMS within the past six months OR currently receiving ECT and TMS is considered a less invasive alternative.see text

These are presented as alternative routes to establish medical necessity in the vignette section.

The following conditions are exclusionary for coverage of rTMS and must be absent for medical necessity: active substance use disorder or eating disorder within the past year; recent history of obsessive–compulsive disorder or post‑traumatic stress disorder; recent history of a psychotic disorder (including schizoaffective disorder), bipolar disease, or major depression with psychotic features; diagnosis of MDD in the context of a current or past manic, mixed, or hypomanic episode; presence of a suicide plan or recent suicide attempt; neurological contraindications such as epilepsy, cerebrovascular disease, dementia, Parkinson’s disease, multiple sclerosis, increased intracranial pressure, history of repetitive or severe head trauma, or primary/secondary CNS tumor; and presence of vagus nerve stimulator leads in the carotid sheath.

rTMS is considered not medically necessary when any of the exclusionary medical or psychiatric conditions listed above are present. In addition, the treating physician must have examined the member, reviewed the record, demonstrate experience administering rTMS, and directly supervise the procedure on site and be immediately available; lack of these supervision/order requirements will render services non‑covered.

Diagnosis and Procedure Codes

Covered ICD-10 Diagnoses (form options)ICD-10Covered

F32.2	Major Depressive Disorder, Single Episode, Severe (Without Psychotic Features)
F33.2	Major Depressive Disorder, Recurrent Episode, Severe (Without Psychotic Features)

Requested CPT CodesCPT

90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment - initial, including cortical mapping, motor threshold determination, and 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 redetermination with delivery and management

Required prior medication trials

Standard requirementMinimum of two adequate trials of psychopharmacologic agents (each ≥6 weeks at adequate dose) from at least two different medication classes in the current depressive episode, documented with standardized rating scales.

Vignette alternative — four trialsLack of response to four trials from two agent classes (alternative pathway to establish resistance per clinical vignette).

Vignette alternative — three trials + augmentationLack of response to three trials from two agent classes plus one augmenting agent (alternative pathway per vignette).

Intolerance pathwayInability to tolerate medications as evidenced by trials of four pharmacologic agents with distinct side effects (acceptable alternative to resistance trials).

Documentation expectationsDetailed prior medication trial documentation required: medication name, dosage, dates, and comments on response/tolerance (provided on the form).

Provider Requirements and Authorization Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for rTMS. Submit the completed Magnetic Stimulation (rTMS) Request Form and any supplemental documentation to Capital Blue Cross Preauthorization (fax: 717.346.5800). For questions contact Preauthorization at 800.471.2242.

Use the rTMS request form; indicate the FDA-approved device and requested CPT code(s) (e.g., 90867, 90868, 90869).
Include proposed start date and number of units/sessions.
Provider ordering must be a physician who has examined the member, reviewed the record, has experience administering rTMS, and directly supervises the procedure (on-site and immediately available).

Step Therapy

Step Therapy / Prior Medication Requirements

Document prior adequate pharmacologic therapy trials. rTMS is indicated for treatment-resistant major depressive disorder after adequate medication trials unless other clinical criteria (e.g., intolerance, prior positive TMS response) apply.

Provide documentation of at least two adequate trials of psychopharmacologic agents during the current depressive episode from at least two different medication classes, each trial of at least six weeks at therapeutic dose, with assessment results from standardized rating scales (GDS, PHQ‑9, BDI, HAM‑D, MADRS, QIDS, or IDS‑SR).

Level of Care Settings

Treatment Modalities

TMS

TMS modality requirements: Use of an FDA-approved TMS device and selection of the appropriate CPT code for the requested service (90867 for initial including cortical mapping and motor threshold determination; 90868 for subsequent delivery per session; 90869 for motor threshold redetermination) as indicated on the request form.see text

Device and CPT code must be specified on the form.

Key Definitions

treatment-resistant depression (definition)

DefinitionTreatment-resistant depression is operationalized on the form as inadequate clinical response to psychopharmacologic treatment — typically failure of at least two adequate trials from different medication classes in the current depressive episode, each of at least six weeks' duration and documented by standardized rating scales.

Alternative definitions (vignette)Also may be defined by lack of response to four trials from two agent classes, or three trials from two classes plus one augmenting agent, or intolerance to four distinct agents — these are presented as alternate routes to establish medical necessity.

Clinical confirmationDiagnosis must be severe MDD (F32.2 or F33.2) with documented pre-treatment rating scale score and treating physician review, per initial treatment criteria.

CPT codes for rTMS services

90867Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment - initial, including cortical mapping, motor threshold determination, and delivery and management.

Background

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive, device‑based neuromodulation treatment used for individuals with treatment‑resistant major depressive disorder (MDD). The request form requires documentation that the member meets severe MDD diagnostic criteria and that alternative treatments have been considered or tried. Clinical eligibility hinges on demonstration of inadequate response to pharmacologic therapy or inability to tolerate medications, absence of exclusionary neurologic or psychiatric conditions, measurement of baseline depressive symptom severity with a standardized rating scale, and direct on‑site supervision by a physician experienced in rTMS.