Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form and Clinical Criteria
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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.
No material clinical or coverage changes in this revision.
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:
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
| F32.2 | Major Depressive Disorder, Single Episode, Severe (Without Psychotic Features) |
| F33.2 | Major Depressive Disorder, Recurrent Episode, Severe (Without Psychotic Features) |
| 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 |
Provider Requirements and Authorization Actions
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 / 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).
- If medication intolerance is claimed, document trials of four psychopharmacologic agents from at least two different classes (at least one an antidepressant) with distinct side effects explaining intolerance.
- Alternative Capital clinical vignette thresholds (document as applicable): lack of response to four trials from two classes; or lack of response to three trials from two classes plus one augmenting agent; or history of positive response to prior TMS (≥ 6 months since prior course); or currently receiving ECT with TMS considered a less invasive alternative.
Required Documentation for Authorization
Submit all required documentation with the prior authorization request. Incomplete documentation may delay or result in denial of authorization.
- Completed rTMS request form with member and provider information, member name/ID/date of birth, and proposed treatment start date.
- Confirmed diagnosis: severe Major Depressive Disorder (F32.2 or F33.2) with date and pretreatment rating scale scores (GDS, PHQ‑9, BDI, HAM‑D, MADRS, QIDS, or IDS‑SR).
- Detailed medication history table listing prior medication trials (name, dosage, dates, response) and standardized rating scale results demonstrating lack of clinically significant response when applicable.
- Description of prior TMS and/or ECT treatments in the past three years, including dates and response.
- Clinical narrative including current symptoms/mental status, history of depression, therapy history, support system, and risk/benefit analysis supporting rTMS.
- Documentation supporting any claimed medication intolerance or other clinical exceptions (e.g., prior positive TMS response, concurrent ECT rationale).
- Evidence the ordering physician meets experience/supervision requirements and that the treating facility/practitioner meets applicable licensure/credentialing requirements.
Triggers for Denial
Failure to provide required prior medication trial documentation, pretreatment rating scales, confirmed diagnosis, or the completed rTMS request form may result in denial of the request.
- Missing documentation of at least two adequate medication trials from different classes (or alternative documented criteria) is a common trigger for denial.
- Omitting pretreatment standardized depression rating scores or lacking dates/duration/doses for prior medications may lead to denial.
- If the ordering provider or facility credentials/experience are not documented, authorization may be denied.
Level of Care Settings
Treatment Modalities
TMS
Device and CPT code must be specified on the form.
Key Definitions
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.
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