ModifiedCentenePolicy CP.BH.201

Deep Transcranial Magnetic Stimulation (dTMS) for Obsessive-Compulsive Disorder

Medical necessity criteria, limitations, and coding guidance for use of deep transcranial magnetic stimulation (dTMS) to treat obsessive-compulsive disorder (OCD) for Centene Advanced Behavioral Health and affiliated Centene plans.

Policy Summary

PayerCentene

PolicyDeep Transcranial Magnetic Stimulation (dTMS) for Obsessive-Compulsive Disorder

Policy CodePolicy CP.BH.201

Change TypeMaterial revisions to coverage criteria and session limits

Effective Date

Next Review Date

Key ActionObtain prior authorization for up to 36 dTMS sessions and document age ≥18, DSM-confirmed OCD, baseline and follow-up Y-BOCS scores, prior medication and CBT/ERP trial details, and the FDA-cleared device to be used.

SourceLink

POLICY UPDATE CHANGES

Changed the initial approved sessions from 30 to up to 36 sessions; recommended schedule five days a week for six weeks with optional six taper sessions.

Added requirement that treatment be administered using an FDA-cleared device and listed example devices (Brainsway H7 coil, MagVenture, Magstim, NeuroStar).

Clarified contraindications and removed several previously listed relative contraindications (history of seizures, severe dementia, severe cardiovascular disease, active suicidal ideation with intent); updated implanted-device contraindications.

Defined clinical response and retreatment thresholds (prior response ≥30% Y-BOCS drop with documented 6-month duration; retreatment reviewed case-by-case).

Specified initial eligibility criteria including age ≥18, DSM diagnosis of OCD, exclusion of multiple psychiatric comorbidities, and failed trials of medication plus CBT/ERP with documented <25% Y-BOCS improvement.

Changed the frequency of services in I.E. from 30 to 36 approved sessions (recommended schedule five days a week for six weeks, with an optional six tapering sessions).

Removed verbiage indicating that the request must be reviewed by a medical director.

up to 36approved dTMS sessions (initial request)

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Coverage and Medical Necessity Criteria

Initial Therapy (Medical Necessity)

Initial treatment of OCD with dTMS is considered medically necessary when ALL of the following are met:

Initial dTMS eligibility: Member is ≥ 18 years old (per DSM) AND has a confirmed DSM diagnosis of obsessive-compulsive disorder (OCD) AND OCD is not part of a presentation with multiple psychiatric comorbidities AND the member failed to respond to a combination of multiple trials of medication combined with Cognitive Behavioral Therapy (CBT) and/or Exposure and Response Prevention (ERP) for at least 12 weeks during the current episode, demonstrated by less than 25% improvement in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) during that trial AND failure to respond to four trials of psychopharmacologic agents representing at least two different agent classes (or documented inability to take required agents due to interactions or intolerance as specified) AND request is for up to 36 sessions (recommended schedule: five days per week for six weeks with an optional six-session taper) AND treatment is administered using an FDA-cleared dTMS device (examples include Brainsway H7 coil, MagVenture, Magstim, NeuroStar) AND direct supervision of treatment is provided by a licensed psychiatrist (unless state scope of practice allows otherwise) AND none of the listed contraindications are present (including magnetic-sensitive metals or implanted stimulators within proximity, less than three months remission from a substance use disorder, known non-adherence, or any other mental health disorder besides OCD).

See device examples and contraindication list in policy.

Maintenance Therapy

Maintenance treatment stance

Maintenance dTMS: Maintenance treatment with dTMS for obsessive-compulsive disorder is considered not medically necessary due to insufficient peer-reviewed literature at this time.

Providers should not request ongoing maintenance dTMS coverage absent new evidence supporting maintenance benefit.

Retreatment

Retreatment (re-initiation) criteria

Retreatment review: Retreatment (re-initiation) of dTMS will be reviewed on a case-by-case basis by medical reviewer and requires: initial dTMS criteria continue to be met; current OCD symptoms have worsened with Y-BOCS > 15; and prior treatment response documented as at least a 30% reduction from baseline with a documented duration of response of 6 months.Y-BOCS > 15; prior response ≥30%

Documented 6-month duration of prior response required; reviewer will consider overall clinical context.

Coverage is not appropriate for members whose presentation includes multiple psychiatric comorbidities or any primary mental health disorder other than obsessive-compulsive disorder (for example, primary mood, psychotic, or other anxiety disorders). Requests may also be excluded when there is known non-adherence to prior OCD treatments, when the member has less than three months of documented remission from a substance use disorder, or when implanted magnetic-sensitive metals or implanted stimulators are present within the proximity limits listed in the policy (see examples in contraindications).

Several relative contraindications that previously appeared in the policy have been removed. Specifically, the policy no longer lists history of seizures, severe dementia, severe cardiovascular disease, or active suicidal ideation with intent as relative contraindications.

Maintenance deep transcranial magnetic stimulation (dTMS) for obsessive-compulsive disorder is considered not medically necessary at this time due to insufficient peer-reviewed literature supporting maintenance treatment.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Required and Billing Codes

Prior authorization is required for deep transcranial magnetic stimulation (dTMS) for OCD. Requests must specify the FDA-cleared device, the number of sessions requested (initial up to 36 sessions), and clinical documentation supporting medical necessity. Use the listed CPT codes for TMS services and reference coding guidance before claim submission.

Prior authorization required and must specify device (e.g., Brainsway H7, MagVenture DB80, Magstim Horizon, NeuroStar) and number of sessions (initial requests up to 36 sessions).
Recommended scheduling: 5 sessions per week for 6 weeks (30 sessions) with an optional up to 6 taper sessions (total maximum initial = 36).
CPT codes commonly used: 90867 (initial TMS treatment including mapping), 90868 (subsequent TMS session), 90869 (motor threshold re-determination with delivery). Review coding guidance prior to billing.

Denial Risk

Requests Exceeding Approved Sessions / Scheduling

Billing Codes and Outcome Measures

Referenced CPT CodesCPT

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.

Referenced HCPCS/Physical Medicine CodesHCPCS

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.

Y-BOCS severity bands and response thresholds

Y-BOCS severity bandsSubclinical <8; Mild 8-15; Moderate 16-23; Severe 24-31; Extreme 32-40.

Common response threshold (25%)A reduction in Y-BOCS score of 25% is often used to define treatment response in trials and guidance.

Alternative response threshold (30-35%)Response is also commonly defined as a 30%–35% reduction in Y-BOCS score; some policy language references 35% as a response criterion.

Definitions and Measurement Tools

dTMS — definition and H-coils

DefinitionDeep Transcranial Magnetic Stimulation (dTMS) is a noninvasive magnetic stimulation technique that uses H-coils to target deeper frontal brain structures implicated in OCD, regulating regions such as the anterior cingulate cortex and medial prefrontal cortex.

H-coilsH-7 coil is an example of an H-coil used to stimulate deeper cortical and subcortical targets relevant to obsessive-compulsive disorder.

Clinical settingDelivered in outpatient/TMS clinic settings with direct supervision by a licensed psychiatrist (unless state scope allows otherwise).

Y-BOCS — definition and scoring

NameYale-Brown Obsessive Compulsive Scale (Y-BOCS)

Description

Site/Level of Care Requirements

Outpatient/TMS clinic

Outpatient/TMS clinic level of care: dTMS is delivered in an outpatient/TMS clinic setting. Admission criteria include adult age (≥18), DSM-confirmed OCD, no multiple psychiatric comorbidities, failed adequate medication plus CBT/ERP trials as specified, and baseline severity consistent with moderate to severe OCD per Y-BOCS when applicable. Continued treatment up to the initially approved course (up to 36 sessions) requires documentation of response trajectory and absence of contraindications. Discharge when treatment goals met or contraindication/ non-adherence emerges.

Policy-level operational details (staffing, scheduling) follow standard outpatient behavioral health/TMS clinic practice and state scope of practice regulations.

Treatment Modalities and Device Use

dTMS

dTMS modality: Deep Transcranial Magnetic Stimulation (dTMS) is a noninvasive magnetic stimulation modality utilizing H-coils to target deeper frontal brain structures implicated in OCD; it is an FDA-cleared treatment when used in accordance with labeled indications and should be delivered per device labeling and clinical protocols.

Recommended initial course: up to 36 sessions (5 days/week for 6 weeks) with optional 6-session taper as indicated.

Deep Transcranial Magnetic Stimulation (dTMS)

Device-specific modality statements: Treatment must be administered using an FDA-cleared dTMS device. Examples cited in the policy include: Brainsway Deep TMS System (H7 coil, K183303), MagVenture TMS Therapy System (cool DB80 coil, K221544), Magstim Horizon 3.0 (K222171), and NeuroStar Advanced Therapy System (K212289).

Providers must document the device used and that treatment followed FDA-labeled indications; device clearances and supporting references are listed in the policy.

Session Limits and Scheduling

dTMS sessions — approved limit

Approved session limitUp to 36 sessions for an initial treatment course.

Policy noteRequest should specify number of sessions up to 36 as part of prior authorization submission.

Approval changeFrequency was changed from 30 to up to 36 approved sessions in policy revision.

dTMS sessions — scheduling recommendation and taper

Approved course and scheduleApproved up to 36 sessions with recommended schedule of 5 sessions per week for 6 weeks.

Optional taperAn optional 6‑session taper may be used following the 6‑week course (policy notes an optional six sessions for tapering).

Background and Rationale

Obsessive-compulsive disorder (OCD) is characterized by intrusive obsessions and repetitive compulsions that cause functional impairment. dTMS is a noninvasive neuromodulation therapy using H-coil technology to target deeper frontal brain regions implicated in OCD; FDA-cleared devices (examples listed in the policy) are required for treatment. Clinical use in this policy is limited to adults (age ≥ 18) with DSM-confirmed OCD who have not responded adequately to combined evidence-based treatments (a course of cognitive behavioral therapy with exposure and response prevention plus multiple adequate pharmacologic trials). The policy authorizes an initial course of up to 36 sessions (recommended five times per week for six weeks with an optional six-session taper) when all eligibility criteria are met, and it defines retreatment considerations (including prior response of at least a 30% reduction in Y-BOCS with a documented 6-month duration) while noting that maintenance courses are not covered.

Policy Revision History

2025-01-30references_updated

References list revised and access dates updated to January 30, 2025.

2025-02-25approval_dateLatest

Policy approval date recorded as 02/25 and entered into policy header.

2024-?sessions_increase

Initial approved sessions revised from 30 to up to 36 sessions with recommended schedule of 5 days/week for 6 weeks and optional 6-session taper.

Policy Summary

PayerCentene

PolicyDeep Transcranial Magnetic Stimulation (dTMS) for Obsessive-Compulsive Disorder

Policy CodePolicy CP.BH.201

Change TypeMaterial revisions to coverage criteria and session limits

Effective Date

Next Review Date

SourceLink

On This Page

Note

Policy Revisions, Approval Dates, and Administrative Notes

Policy revisions, approval dates, and provider-facing administrative notes: providers should include approval dates and documentation of prior response durability when requesting retreatment. The policy was revised to remove routine medical director review for initial approvals and to increase the approved initial session limit to 36. Ensure submitted records reference the documented 6-month duration of response when applicable.

Policy updated: initial session limit changed from 30 to 36; routine medical director review for initial requests removed.
Providers should include approval date(s) of prior dTMS courses and evidence of a documented 6-month duration of response when applicable.
Keep submitted documentation current and aligned with the latest policy revision and approval dates.

Step Therapy

Step Therapy Requirement

Step therapy is required prior to approval of dTMS: members must have failed an adequate course of combined psychotherapy (CBT and/or ERP) plus multiple medication trials as specified below.

Required failure of combined CBT and/or ERP plus medication trials for at least 12 weeks during the current episode.
Failure to respond to pharmacotherapy is defined as lack of clinically significant response after four trials of agents representing at least two different classes (including at least two adequate SSRI/SNRI/clomipramine or atypical antipsychotic augmentation trials of ≥12 weeks where applicable).
If medications are contraindicated or not tolerated, document drug interactions or intolerance with trials of four distinct agents in the current episode.

Documentation Required

Required Documentation for Prior Authorization

Required documentation must accompany prior authorization requests to demonstrate medical necessity and eligibility for dTMS.

Member age (must be ≥ 18 years) and DSM-confirmed diagnosis of OCD.
Baseline Y-BOCS score and follow-up Y-BOCS scores showing <25% improvement during the current episode for eligibility; for retreatment, prior response documented as ≥30% drop and sustained for 6 months.
Details of prior treatment trials: dates, agents, doses, durations (≥12 weeks where applicable), classes represented, psychotherapy (CBT/ERP) details, and reasons for discontinuation or intolerance.
Device used or proposed (manufacturer/model) and number of sessions requested (specify up to 36 initial sessions and proposed schedule).
Evidence ruling out contraindications (e.g., implanted magnetic-sensitive metals within 30 cm of coil, implanted stimulators).

Denial Risk

Triggers for Denial

Common triggers for denial include age under 18, absence of DSM-confirmed OCD, presence of multiple psychiatric comorbidities that confound diagnosis, insufficient prior treatment trials or psychotherapy, and requests exceeding session limits.

Member < 18 years of age.
No DSM-confirmed diagnosis of OCD documented.
OCD occurring as part of a presentation with multiple psychiatric comorbidities (policy excludes other primary mental health disorders).
Insufficient prior treatment trials (fewer than required medication trials or inadequate CBT/ERP), or lack of documentation of adequate duration/response.
Requests that exceed the 36-session initial limit or lack adequate justification for deviation from recommended schedule.