CurrentCentenePolicy CP.BH.200

Transcranial Magnetic Stimulation for Treatment-Resistant Major Depression

Defines medical necessity criteria, age-specific review rules, contraindications, device requirements, session limits, and Not Medically Necessary positions for maintenance and MRI-guided accelerated TBS for TMS treatments for major depressive disorder.

Policy Summary

PayerCentene

PolicyTranscranial Magnetic Stimulation for Treatment-Resistant Major Depression

Policy CodePolicy CP.BH.200

Change TypeRevised — multiple updates including session limits and adolescent criteria

Effective Date

Next Review Date

Key ActionRequests for initial treatment in adolescents 15–17 and for retreatment require case-by-case review by a medical director using the listed clinical criteria.

POLICY UPDATE CHANGES

Policy/Criteria updated to specify initial authorization up to 36 sessions and added device examples and other clarifications.

Added policy statement that there is insufficient evidence to support safety and efficacy of more than 30 sessions of TBS.

Added deep TMS (dTMS) as a form of TMS for adults ≥ 18 years.

Changed documentation requirements to require planned use of standardized depression rating scale with pre-TMS score documented.

Added adolescents 15-17 year-old policy statements (II and IV).

Removed HCPCS coding table including G0295.

Removed several relative contraindications (history of seizures, severe cardiovascular disease, acute psychotic disorders in current episode, dementia, active suicidal ideation with intent) and later re-added acute active suicidal ideation with intent as a contraindication.

Clarified pharmacologic trial requirements: failure or intolerance to two trials of antidepressants from at least two different agent classes; intolerance requires both criteria of intolerance and discontinuation.

36Max sessions authorized (initial/retreatment)

30Max TBS sessions (policy limit)

>=15PHQ-9/PHQ-A threshold for severity

≥18Adult population covered

15-17Adolescent age group added

Not medically necessaryMaintenance rTMS

Coverage Summary

This policy defines medical necessity criteria for Transcranial Magnetic Stimulation (TMS) therapies for major depressive disorder. Covered populations include adults aged ≥ 18 years, and adolescents aged 15–17 years who will be reviewed case-by-case by a medical director under specified conditions. Covered TMS modalities include repetitive TMS (rTMS), deep TMS (dTMS), and intermittent Theta Burst Stimulation (iTBS/TBS). The policy takes a mixed coverage stance: it allows initial and retreatment courses when detailed clinical criteria are met but places limits and exclusions on certain modalities and uses.

Session limits are specified: initial and retreatment requests are authorized for up to 36 sessions (recommended schedule five days/week for six weeks, with an optional six taper sessions). A separate policy statement limits Theta Burst Stimulation to no more than 30 sessions. Maintenance treatment with rTMS, dTMS, or iTBS is designated Not Medically Necessary, and MRI-guided/accelerated TBS (e.g., SAINT) is considered investigational and not supported by sufficient evidence.

Key thresholds and quick facts

Max sessions authorized (initial/retreatment)36 sessions

Max TBS sessionsNo more than 30 TBS sessions

PHQ threshold>= 15 (PHQ-9 / PHQ-A) throughout the current course

Minimum SUD remissionAt least 3 months substantiated remission

Adolescent age groupAges 15-17 (case-by-case review)

Adult population coveredAdults ≥ 18 years

I. Initial treatment (Adults ≥ 18 years)

II. Initial treatment (Adolescents 15–17) — case-by-case

II. Initial treatment (Adolescents ages 15–17)

Requests for initial treatment with rTMS for adolescents 15–17 will be reviewed case-by-case by a medical director, informed by ALL of the following:

ALL of the following

Treatment administered using NeuroStar TMS Therapy System as adjunct per FDA-labeled indication
Confirmed diagnosis of MDD, severe (single episode or recurrent), per DSM (most recent edition)
No diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder
Failed pharmacologic therapy (ONE of)

III. Retreatment (Adults ≥ 18 years) — case-by-case

III. Retreatment (Adults ≥ 18 years)

Requests for retreatment with rTMS, dTMS or iTBS for adults will be reviewed case-by-case by a medical director, informed by ALL of the following:

ALL of the following

Confirmed diagnosis of MDD, severe (single episode or recurrent), per DSM (most recent edition)
No diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder
Current depressive symptoms worsened to PHQ-9 severity score ≥ 15 (or equivalent)>= 15
Prior treatment response demonstrated at least a 50% improvement in baseline standardized depression rating scores with a documented 6-month duration of response

IV. Retreatment (Adolescents 15–17) — case-by-case

IV. Retreatment (Adolescents ages 15–17)

Requests for retreatment with rTMS for adolescents 15–17 will be reviewed case-by-case by a medical director, informed by ALL of the following:

ALL of the following

Requested treatment is with NeuroStar TMS Therapy System, as adjunct per FDA-labeled indication
Confirmed diagnosis of MDD, severe (single episode or recurrent), per DSM (most recent edition)
No diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder
Current depressive symptoms worsened to PHQ-A severity score ≥ 15 (or equivalent)>= 15

V–VI. Maintenance & MRI-guided / Accelerated TBS

V–VI. Maintenance treatment and MRI‑guided/accelerated TBS (Not medically necessary / Investigational)

Maintenance rTMS and MRI-guided/accelerated TBS protocols

ALL of the following

Maintenance treatment with rTMS, iTBS or dTMS is considered not medically necessary due to insufficient evidence
There is insufficient evidence to support the safety and efficacy of MRI-guided theta burst stimulation, including but not limited to SAINT, beyond established TMS/TBS techniques (considered investigational)
There is insufficient evidence to support safety and efficacy of more than 30 sessions of TBS; TBS > 30 sessions not coveredTBS <= 30 sessions

Adults (≥ 18 years) - Policy Statement I (covered with clinical criteria)

Adults (≥ 18 years) - Policy Statement I (consolidated)

Coverage criteria consolidated for adults (Policy Statement I) — requirements, exclusions, documentation, and session limits:

ALL of the following

Diagnosis of major depressive disorder (MDD) in adults (≥ 18 years)
The member/enrollee does not have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder
Documentation that the member has participated in an adequate trial of evidence-based psychotherapy during the current episode without significant improvement
Therapy should overlap with antidepressant trials
Failure or intolerance to two trials of antidepressants from at least two different agent classes (intolerance requires documentation and discontinuation); some iterations specify at least 4 antidepressants representing at least 2 classes

Coding

CPT codes referencedCPT

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.
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended).
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.

Removed/Deleted HCPCS codesHCPCS

G0295

Removed from HCPCS coding table in policy; no longer listed in this document part.

Category III CPT codes referenced in referencesCPT

0889T-0892T

Category III codes referenced by Hayes medical code brief for accelerated, MRI-guided theta-burst stimulation.

Provider Actions

Prior Authorization

Medical director case-by-case review for adolescents and retreatment

Requests for initial TMS in adolescents (15–17) and for retreatment require review by a medical director on a case-by-case basis informed by the policy criteria (diagnosis, prior treatment response, current severity, supervision, device, contraindications, documentation, and session limits).

Documentation Required

Clinical documentation requirements

Document the following in the record when requesting TMS: diagnosis, prior antidepressant medication trials (classes, durations, and documentation of intolerance/discontinuation when applicable), evidence of psychotherapy trials overlapping with medication trials, standardized depression rating scores (PHQ-9 or PHQ-A or equivalent) documented prior to and monitored throughout treatment, prior ECT status (failed trial or contraindication), and the specific TMS protocol and device used (rTMS, iTBS/TBS, or dTMS; FDA-cleared device).

Background, Evidence & Definitions

TMS modalities described include conventional repetitive TMS (rTMS)—typically delivered ≥10 Hz to the dorsolateral prefrontal cortex—deep TMS (dTMS) using H-coils to reach deeper (~4 cm) targets, and Theta Burst Stimulation (iTBS/TBS), which uses short high-frequency bursts (e.g., 50 Hz bursts producing an overall 5 Hz pattern).

The FDA has issued multiple clearances: conventional rTMS was cleared in 2008, dTMS in 2013, iTBS in August 2018, and in 2024 the FDA approved the NeuroStar Advanced Therapy as an adjunct for treatment of MDD in adolescents aged 15–21 years.

Overall evidence in adults includes randomized controlled trials and systematic reviews showing benefit of TMS for treatment-resistant depression (for example, a network meta-analysis reported an increased odds of response with TMS versus sham at six weeks). Systematic reviews of theta burst report superiority to sham for response (relative risk around 2.4) and no clear difference versus conventional rTMS. For adolescents, randomized evidence is mixed: a multicenter double-blind RCT of 10-Hz NeuroStar in adolescents (aged 12–21) found no significant difference between active and sham on the HAM-D-24 after six weeks.

Study / Source	Finding
Network meta-analysis (rTMS vs sham)	OR 8.6 (95% CI 1.2–112.6) for response at 6 weeks
Theta burst systematic review/meta-analysis (Voigt et al., 2021)	RR 2.4 (95% CI: 1.27–4.55) for response vs sham; no difference vs conventional rTMS
Adolescent RCT (Croarkin et al., NeuroStar 10‑Hz)	No significant difference between active and sham on HAM‑D‑24 after 6 weeks (active −11.1 vs sham −10.6; P=0.8); response and remission rates similar
FDA device approvals summary	FDA cleared conventional rTMS (2008), dTMS (2013), iTBS (2018); NeuroStar approved as adjunct for adolescents aged 15–21 in 2024
Hayes evidence brief / Medical code brief	Hayes found weak support for iTBS and MRI guidance; no guidelines for accelerated MRI‑guided TBS (codes 0889T‑0892T)

rTMS: Repetitive transcranial magnetic stimulation delivering trains of magnetic pulses, commonly at frequencies ≥ 10 Hz targeting the dorsolateral prefrontal cortex.

dTMS: Deep transcranial magnetic stimulation using H-coils to reach deeper brain structures (approximately 4 cm depth) and stimulate a wider cortical region.

iTBS (Theta Burst Stimulation): Short bursts of 3–5 pulses at ~50 Hz with interburst intervals producing an overall ~5 Hz stimulation pattern; also referred to as TBS or intermittent TBS (iTBS).

Revision History

12/18revision

Policy reviewed, updated, and adopted as Centene Corporate policy; initial structuring and adoption recorded in revision log.

02/19revision

Restructured language regarding failure of or intolerance to psychopharmacologic agents (no wording changes).

05/20revision

Policy updated to clarify oversight by a licensed psychiatrist; initial request could be reviewed for up to 20 TMS sessions; added adolescent criteria section.

Policy Summary

PayerCentene

PolicyTranscranial Magnetic Stimulation for Treatment-Resistant Major Depression

Policy CodePolicy CP.BH.200

Change TypeRevised — multiple updates including session limits and adolescent criteria

Effective Date

Next Review Date

Key ActionRequests for initial treatment in adolescents 15–17 and for retreatment require case-by-case review by a medical director using the listed clinical criteria.

On This Page

PHQ-A score ≥ 15 throughout current course (or other equivalent), indicating moderately severe to severe depression

Documentation of failure of two trials of antidepressants from at least two different antidepressant classes administered as an adequate course with a recognized standard therapeutic dose of at least six weeks duration within the last 24 months>= 6 weeks

Inability to tolerate two trials of antidepressants from at least two different antidepressant classes within the last 24 months (documentation of major adverse interactions or intolerable side effects)

Participation in adequate trial of evidence-based psychotherapy during current episode without significant improvement (therapy should overlap with antidepressant trials)

ECT requirement (ONE of)

Failed trial of ECT
ECT contraindicated or psychiatrist documents why TMS is preferable

Referred for TMS by the provider treating the adolescent's MDD

Comprehensive psychiatric evaluation completed by (ONE of)

Psychiatrist (MD, DO, or MBBS)
Psychiatric Nurse Practitioner

Direct supervision by a licensed psychiatrist trained in TMS therapy unless state scope allows otherwise

Request is for up to 36 sessions (recommended schedule: 5 days/week for 6 weeks, optional 6 taper sessions)Up to 36 sessions

No contraindications (ALL of)

No conductive or ferromagnetic metals implanted/embedded in head/neck within 30 cm of coil placement (other than dental fillings)
No vagus nerve stimulator leads in carotid sheath
At least three months of substantiated remission from substance use disorder>= 3 months
Not receiving concomitant esketamine intranasal, ketamine infusion or other infusion therapies

Documentation of rTMS protocol used

Planned use of an adolescent evidence-based standardized depression rating scale documenting score prior to treatment and monitored throughout treatmentPre-TMS score documented

Hayes evidence reviews and medical code briefs are referenced in the policy background and informed revisions: Hayes published a June 21, 2024 evidence brief on TMS in adolescents and a January 25, 2024 medical code brief on MRI-guided accelerated TBS codes; their reviews noted weak or limited support for MRI guidance and intermittent TBS and contributed to the policy's more cautious, case-by-case approach for adolescents. Adolescent randomized trial evidence is mixed — notably a multicenter NeuroStar 10-Hz adolescent RCT did not find active TMS superior to sham on HAM-D-24, which supports the policy's conditional, medical-director review approach for ages 15–17.

>= 50% improvement; >= 6 months duration

Referred for TMS by the provider treating the member's MDD

Comprehensive psychiatric evaluation completed by (ONE of)

Psychiatrist (MD, DO, or MBBS)
Psychiatric Nurse Practitioner

Participated in an adequate trial of evidence-based psychotherapy during the current episode without significant improvement

Direct supervision provided by a licensed psychiatrist trained in TMS therapy unless state scope allows otherwise

Request is for up to 36 sessions (recommended schedule: 5 days/week for 6 weeks, optional 6 taper sessions)Up to 36 sessions

FDA-cleared device used (examples include)

NeuroStar Advanced TMS Therapy System
Apollo TMS Therapy System
BrainsWay Deep TMS
Horizon TMS Therapy System
MagVita TMS Therapy with MagPro R20
MagVita TMS Therapy System w/Theta Burst Stimulation
Neurosoft TMA (Cloud TMS)
Nexstim Brain Therapy
Magstim Horizon 3.0 TMS Therapy System Range

No contraindications (ALL of)

No conductive or ferromagnetic metals implanted/embedded in head/neck within 30 cm of TMS coil placement (other than dental fillings)
No vagus nerve stimulator leads in the carotid sheath
At least three months of substantiated remission from substance use disorder>= 3 months
Not receiving concomitant esketamine intranasal, ketamine infusion or other infusion therapies

Documentation of rTMS, iTBS or dTMS protocol used

Planned use of an evidence-based standardized depression rating scale documenting the score prior to treatment and monitored throughout treatmentPre-TMS score documented

If not achieving remission, consider treatment augmentation or alternative such as ECT

Prior treatment response demonstrated at least a 50% improvement in baseline standardized depression rating scores with a documented 6-month duration of response>= 50% improvement; >= 6 months duration

Referred for TMS by the provider treating the adolescent's MDD

Comprehensive psychiatric evaluation completed by (ONE of)

Psychiatrist (MD, DO, or MBBS)
Psychiatric Nurse Practitioner

Participated in an adequate trial of evidence-based psychotherapy during the current episode without significant improvement

Direct supervision provided by a licensed psychiatrist trained in TMS therapy unless state scope allows otherwise

Request is for up to 36 sessions (recommended schedule: 5 days/week for 6 weeks, optional 6 taper sessions)Up to 36 sessions

No contraindications (ALL of)

No conductive or ferromagnetic metals implanted/embedded in head/neck within 30 cm of coil placement (other than dental fillings)
No vagus nerve stimulator leads in carotid sheath
At least three months of substantiated remission from substance use disorder>= 3 months
Not receiving concomitant esketamine intranasal, ketamine infusion or other infusion therapies

Documentation of rTMS protocol used

Planned use of an evidence-based standardized depression rating scale documenting the score prior to treatment and monitored throughout treatmentPre-TMS score documented

If not achieving remission, consider augmentation or alternative such as ECT

Referral for TMS treatment by the provider treating the member's MDD

Comprehensive psychiatric evaluation completed by a qualified licensed provider (MD, DO or MBBS)

Planned use of a standardized depression severity rating scale by the TMS provider to monitor response during treatment, with pre-TMS score documentedPre-TMS score documented

Documentation of rTMS, iTBS/TBS or dTMS protocol used

Not experiencing concomitant esketamine intranasal, ketamine infusion or other infusion therapies

Not experiencing acute active suicidal ideation with intent

Frequency and total session limits: Up to 36 sessions; recommended schedule five days a week for six weeks with optional six tapering sessions; TBS limited to no more than 30 sessionsUp to 36 sessions; TBS <= 30 sessions

Diagnosis (confirmed MDD, severe per DSM)

Prior medications: antidepressant classes attempted, adequate durations (≥6 weeks), and documentation of intolerance/discontinuation if applicable

Psychotherapy trial(s): evidence-based psychotherapy participation overlapping with antidepressant trials

PHQ-9 (adults) or PHQ-A (adolescents) or equivalent standardized scale: pre-TMS score and monitoring throughout treatment

ECT status: failed ECT or documentation that ECT is contraindicated or why TMS is preferable

TMS protocol and device: document rTMS, iTBS/TBS or dTMS protocol used and FDA-cleared device

Denial Risk

Contraindication denial conditions

Claims may be denied if any of these contraindication conditions are present: implanted conductive/ferromagnetic or other magnetic-sensitive materials in the head/neck within 30 cm of the coil (examples below), vagus nerve stimulator leads in the carotid sheath, less than three months of substantiated remission from a substance use disorder, or concurrent esketamine intranasal, ketamine infusion, or other infusion therapies.

Implanted magnetic-sensitive materials within 30 cm of coil placement (e.g., cochlear implant; implanted electrodes/stimulators; aneurysm clips/coils; stents; bullet fragments; metallic tattoo dyes)
Vagus nerve stimulator leads in the carotid sheath
Substance use disorder remission less than 3 months
Concurrent esketamine intranasal, ketamine infusion or other infusion therapies

Billing Rule

Session limit

Use CPT codes 90867 (initial TMS), 90868 (subsequent delivery and management), and 90869 (subsequent motor threshold re-determination with delivery and management). Authorizations are for up to 36 sessions (recommended schedule: 5 days/week × 6 weeks) with an optional up to 6 taper sessions. Maintenance rTMS, iTBS/TBS or dTMS is considered not medically necessary.

Relevant CPT codes: 90867, 90868, 90869
Session limit: up to 36 sessions (recommended 5 days/week × 6 weeks)
Optional up to 6 taper sessions
Maintenance rTMS/iTBS/dTMS: Not medically necessary

Documentation Required

Standardized depression rating scale and pre-TMS score

Planned use of a standardized depression severity rating scale is required with the pre-TMS score documented and ongoing monitoring of scores throughout the course of treatment (PHQ-9 for adults, PHQ-A or equivalent for adolescents).

Documentation Required

Comprehensive psychiatric evaluation

A comprehensive psychiatric evaluation must be completed by a qualified licensed provider (Psychiatrist MD/DO/MBBS or Psychiatric Nurse Practitioner) prior to initiating TMS or retreatment.

Prior Authorization

Session limits and modality restrictions

For prior authorization, ensure total sessions requested do not exceed policy limits: up to 36 sessions overall; Theta Burst Stimulation (TBS/iTBS) limited to no more than 30 sessions per policy. MRI-guided theta burst (e.g., SAINT) is considered investigational and should not be authorized.

Total sessions must not exceed policy limits (up to 36 sessions overall)
TBS/iTBS session cap: no more than 30 TBS sessions
MRI-guided/accelerated TBS (including SAINT) is investigational — not authorized

Documentation Required

Treatment protocol documentation

Document the specific treatment protocol used (rTMS, iTBS/TBS, or dTMS) in the medical record, including stimulation parameters and device used.

Denial Risk

Contraindications

Do not authorize TMS for members with excluded diagnoses or concurrent excluded therapies: schizophrenia, schizoaffective disorder, or bipolar disorder; concurrent esketamine intranasal, ketamine infusion, or other infusion therapies; or acute active suicidal ideation with intent — presence of these conditions constitutes a denial risk.

Diagnostic exclusions: schizophrenia, schizoaffective disorder, bipolar disorder
Concurrent therapy exclusions: esketamine intranasal, ketamine infusion, other infusion therapies
Acute active suicidal ideation with intent is a contraindication and denial condition

TBS (general): Theta Burst Stimulation, an accelerated or patterned form of rTMS that may be delivered in standard or accelerated protocols; MRI-guided accelerated TBS protocols (e.g., SAINT) are considered investigational by this policy.

02/21revision

Changed medical necessity statements to require medical director review; edits clarified review process; included SAINT/accelerated iTBS background and noted high-dose protocols in literature.

02/22revision

Initial sessions revised from 30 to 20 in Policy/Criteria (historical change), added statements about additional sessions authorization and ECT reference; annual review updates.

06/22revision

Replaced various wording, adjusted remission language for substance use disorder, and added authorization for six tapered final sessions in revised criteria.

08/22material_revision

Initial number of sessions changed from 20 to 30; additional sessions revised from 20 to 6; clarified up to 36 sessions (later iterations) and added taper sessions guidance.

11/22revision

Policy restructured; added criteria that all initial criteria must be met prior to additional sessions; clarified contraindication timing (three months remission).

02/23material_revision

Added frequency of sessions (5 days/week for 6 weeks); explicitly allowed up to a total of 30 TBS sessions; added FDA-cleared device examples; required planned use of standardized rating scale and pre-TMS score documentation; added contraindication 'acute active suicidal ideation with intent' and clarified intolerance documentation; instituted new policy statement II limiting TBS sessions to no more than 30.

03/23approval

Approval documented for the TBS session limit policy statement reiterating insufficient evidence to support >30 TBS sessions.

03/24material_revision

Clarified pharmacologic trial requirements: failure or intolerance to two trials of antidepressants from at least two different agent classes; intolerance requires documentation and discontinuation; specified that at least 4 antidepressants representing at least 2 different classes must have been attempted for intolerance pathway; removed HCPCS coding table including G0295; added dTMS to adult policy statements and created separate adolescent policy statements (II and IV).

02/25material_revisionLatest

Current policy structure finalized: initial/retreatment requests limited to up to 36 sessions (recommended 5 days/week for 6 weeks with optional 6 taper sessions); adolescent (15–17) statements added and to be reviewed case-by-case using NeuroStar per FDA labeling; dTMS included for adults; MRI-guided theta-burst/accelerated protocols (e.g., SAINT) deemed investigational; maintenance rTMS considered not medically necessary; documentation requirement changed to planned use of standardized depression rating scale with pre-TMS score documented; contraindication list adjusted to include 'not experiencing acute active suicidal ideation with intent' and to exclude schizophrenia/schizoaffective/bipolar diagnoses; coding table removal and other clarifications applied.