ModifiedCentenePolicy CP.BH.201

Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder

Medical necessity and coverage criteria for using deep transcranial magnetic stimulation to treat adults with obsessive-compulsive disorder for Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyDeep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder

Policy CodePolicy CP.BH.201

Change TypeMaterial clinical and operational revisions (sessions, response threshold, device requirements, codes)

Effective Date

Next Review Date

Key ActionObtain prior authorization documenting age ≥18, DSM-confirmed OCD, baseline and follow-up Y-BOCS scores, failed therapy trials, and planned use of an FDA-cleared dTMS device for up to 36 sessions.

SourceLink

POLICY UPDATE CHANGES

Initial request sessions changed from 20 to 30 sessions.

Requirement that dTMS be administered using an FDA-cleared device and in accordance with FDA labeled indications; list of FDA approved devices added.

Tapering request language changed to a taper of six final sessions instead of an additional 10 sessions.

Response thresholds for continued treatment changed from 25%/50% reductions to 30% reductions in OCD symptom severity/baseline scores.

Frequency of services changed from 30 to 36 approved sessions (recommendation: five days/week for six weeks, with optional six taper sessions).

Added contraindication: no active suicidal ideation with intent.

Removed certain relative contraindications (history of seizures, severe dementia, severe cardiovascular disease, and active suicidal ideation with intent) from I.H.

New CPT/HCPCS codes added: 97014 and 97032.

30initial request sessions (revised)

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Coverage Criteria for dTMS (OCD)

Initial Therapy

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

Initial dTMS medical necessity: Member/enrollee is ≥18 years old; confirmed DSM diagnosis of obsessive-compulsive disorder (OCD); OCD is not part of a presentation with multiple psychiatric comorbidities; referred for TMS by the provider treating the OCD symptoms; planned use of the Yale‑Brown Obsessive Compulsive Scale (Y‑BOCS) documenting baseline and monitored throughout treatment; request is for up to 36 sessions (recommended schedule five days/week for six weeks with optional six-session taper); treatment administered using an FDA‑cleared device and in accordance with FDA‑labeled indications; direct supervision provided by a licensed psychiatrist except where state scope of practice allows other provider types to supervise; no contraindicated conductive or ferromagnetic metals implanted or embedded in the head/neck within 30 cm of coil placement; at least three months of substantiated remission from a substance use disorder; no known non‑adherence with previous OCD treatment; no other primary mental health disorder besides OCD.all conditions required

See subcriteria for failed treatment definition

Failed treatment definition: Failure to respond to psychopharmacologic agents in the current OCD episode is defined as lack of clinically significant response to four trials of agents representing at least two different agent classes, with at least two trials adequate SSRI/SNRI/clomipramine or atypical antipsychotic augmentation at standard therapeutic doses for ≥12 weeks; or inability to take those agents due to drug interactions or intolerance evidenced by trials of four agents with distinct side effects; AND failure to respond to a combination of multiple medication trials plus CBT and/or ERP for at least 12 weeks during the current episode as demonstrated by less than 25% improvement in Y‑BOCS.all conditions required

Quantifies medication and psychotherapy failure

Initial Therapy (revised operational items)

Covered when ALL of the following are met:

Initial dTMS treatment (revised operational items): Member/enrollee has a diagnosis of OCD per DSM‑5‑TR; treatment is planned using an FDA‑cleared device and in accordance with FDA‑labeled indications (examples of cleared systems listed in policy); direct supervision provided by appropriate licensed clinician per state scope; planned use of Y‑BOCS for severity assessment with documented baseline prior to treatment; initial request for treatment up to 30 sessions (policy updated).

Operational changes: initial request sessions changed from 20 to 30; device and indication requirements clarified; list of example devices added.

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.all conditions required

Policy explicitly states maintenance is not supported at this time.

Retreatment

Retreatment/Repeat course

Retreatment review criteria: Retreatment with dTMS will be reviewed on a case‑by‑case basis by a medical director; criteria for initial dTMS treatment must continue to be met; current OCD symptoms have worsened with Y‑BOCS scores >15; prior treatment response was at least a 30% drop from baseline OCD scores with a documented 6‑month duration of response.all conditions required

Medical director review and documented prior response/duration required.

Continuation/Taper Therapy

Continued dTMS or taper covered when ALL of the following are met:

Continuation/Taper: Criteria for initial dTMS treatment continue to be met; documented response defined as ≥30% reduction in OCD symptom severity (Y‑BOCS) from baseline; request for taper of six final sessions allowed (policy replaced prior additional‑session language); total approved sessions may be up to 36 including taper.30%

Documentation of response required; adherence to initial criteria and session limits required.

The policy lists implanted conductive or ferromagnetic materials within 30 cm of the dTMS coil placement as a contraindication. Examples explicitly enumerated include cochlear implants, implanted electrodes/stimulators, aneurysm clips/coils, stents, bullet fragments, metallic tattoo dyes, vagus nerve stimulator leads (carotid sheath), and other implanted stimulators such as deep brain stimulation systems, cardiac pacemakers, cardioverter defibrillators, intracardiac lines, and medication pumps. Ensure device screening documents proximity of any metallic or magnetic‑sensitive implant to the planned coil placement before authorizing treatment.

Recent revisions removed pregnancy and certain neurological disease/brain injury language from the contraindication list; consult the current contraindication section for the explicit exclusions. The policy also added a specific contraindication of no active suicidal ideation with intent and clarifies that taper requests are for six final sessions rather than an additional ten sessions. Administrative and device requirements were clarified: dTMS must be performed with an FDA‑cleared device and per labeled indications, and supervision must meet state scope‑of‑practice rules.

The policy explicitly states that maintenance treatment with dTMS for OCD is considered not medically necessary because there is insufficient peer‑reviewed literature supporting ongoing maintenance therapy. Requests for ongoing maintenance beyond the covered initial/continuation course should be evaluated against this stance and are generally not supported.

Authorization and continuation decisions require documentation of objective OCD severity measures. Providers must document baseline and follow‑up Yale‑Brown Obsessive Compulsive Scale (Y‑BOCS) scores and show the required response thresholds (e.g., ≥30% reduction from baseline for continuation). Requests that do not include baseline and subsequent Y‑BOCS measurements demonstrating the specified response, or that exceed the stated session limits without justification, may be denied.

Coding and Severity Metrics

Referenced CPT codes for TMS and related modalitiesCPT

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.

Additional CPT/HCPCS codes listed in policyCPT

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 thresholds — moderate/severe

Moderate Y-BOCS range16–23

Severe Y-BOCS range24–31

Minimum severity referenced for treatment considerationModerately severe to severe; minimum score referenced as 24

Response threshold for continued treatment

Response threshold for continued treatment≥ 30% reduction in OCD symptom severity from baseline (revised)

Documentation requiredObjective OCD severity scores (e.g., Y-BOCS) demonstrating the percent reduction must be provided

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for deep TMS (dTMS) for OCD. Requests must demonstrate the member/enrollee meets all initial-therapy criteria (age ≥18; confirmed DSM diagnosis of OCD; referral from treating OCD provider; documentation of prior adequate trials of psychotherapy and medications; use of an FDA‑cleared device; planned Y‑BOCS monitoring). Initial requests should be for up to 30 sessions; requests may be approved for up to 36 sessions total (includes up to 6 taper sessions).

Initial requests: up to 30 sessions; up to 36 sessions may be approved (includes optional 6-session taper).
Member/enrollee must be ≥ 18 years old and have a confirmed DSM OCD diagnosis.
Referral by the provider treating the OCD symptoms is required.
Treatment must be delivered using an FDA‑cleared device and in accordance with labeled indications.

Documentation Required

Y‑BOCS Documentation Required

Authorization requests must include objective baseline and ongoing OCD severity measurement using the Yale‑Brown Obsessive Compulsive Scale (Y‑BOCS). Include the baseline Y‑BOCS score prior to initiation and subsequent scores documenting clinical response throughout the course of treatment.

Background and Definitions

Obsessive‑compulsive disorder (OCD) is a chronic disorder of obsessions and compulsions. Deep transcranial magnetic stimulation (dTMS) is a noninvasive neurostimulation technique designed to reach deeper brain regions implicated in OCD and was FDA cleared as an adjunctive treatment for adults with OCD. The policy requires use of an FDA‑cleared device (examples listed include the Brainsway H7 coil and other cleared systems), direct supervision by an appropriately licensed clinician per state scope, and use of standardized outcome measurement with the Y‑BOCS to document baseline severity and treatment response. Initial courses are specified with a recommended schedule (five days per week for six weeks) and updated session limits (initial requests updated to 30 sessions, with up to 36 sessions allowed including an optional six‑session taper).

Definition of Y-BOCS — scale and severity bands

Scale descriptionY-BOCS is a standardized 10-item clinician-rated scale; items rated 0–4, total score 0–40

Scoring detailsSum of first five items indexes obsessions; sum of last five indexes compulsions; total provides overall severity

Severity band examplesSubclinical <8; Mild 8–15; Moderate 16–23; Severe 24–31; Extreme 32–40

Treatment Modalities and Device Examples

TMS/dTMS — modality node (examples of FDA-cleared devices/coils referenced)

TMS/dTMS modality criteria: Treatment must be administered using an FDA‑cleared device and utilized in accordance with FDA‑labeled indications; examples of devices/coils referenced in policy include Brainsway Deep TMS System (H7 coil), MagVenture TMS Therapy System (cool DB80 coil), Magstim Horizon 3.0 (with E‑z Cool Coil), NeuroStar Advanced Therapy System, and Apollo TMS Therapy System; treatment should be delivered per labeled parameters under appropriate clinical supervision.all required

TMS — treatment modality node

TMS modality criteria: Device must be FDA‑cleared and used per labeled indications; clinicians should follow the recommended schedule (five days/week for six weeks) with optional taper and use standardized measures (Y‑BOCS) to assess baseline severity and treatment response.

Level of Care — Outpatient Criteria

Outpatient — level of care criteria

Outpatient level of care: Admission for outpatient dTMS: adult (≥18) with DSM‑confirmed primary OCD, treatment‑resistant as defined by required psychotherapy (CBT/ERP) and medication trials, referred by treating provider, baseline Y‑BOCS documented, absence of disqualifying implants or comorbid psychiatric disorders; continued stay: ongoing Y‑BOCS monitoring and absence of contraindications with adherence to supervision requirements; discharge per treating clinician when treatment course complete or no further benefit anticipated.all required

Visit Limits and Session Counts

dTMS sessions — up to 36 sessions

Maximum sessions (course)Up to 36 sessions (recommended schedule: five days/week for six weeks, with optional six-session taper)

Request languagePolicy states requests may be for up to 36 sessions; initial and tapering details specified elsewhere

Note on schedulingRecommended schedule is five days a week for six weeks; optional six taper sessions included in the 36-session maximum

dTMS sessions — 36 (explicit session count)

Explicit session countInitial request updated to 30 sessions (policy revision) with up to 36 sessions allowed including taper

Operational changeInitial request sessions changed from 20 to 30 in the revised policy language

Policy Revision History

02/23operational

Initial request sessions revised from 20 to 30 sessions; device/indication language added requiring use of FDA‑cleared devices and listing examples of approved devices.

03/23operational

Policy added device/indication clarifications and restructured criteria; administrative formatting and approval recorded.

03/24billing

New CPT/HCPCS codes 97014 and 97032 added to the policy coding section.

Policy Summary

PayerCentene

PolicyDeep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder

Policy CodePolicy CP.BH.201

Change TypeMaterial clinical and operational revisions (sessions, response threshold, device requirements, codes)

Effective Date

Next Review Date

SourceLink

On This Page

Documentation Required

Documentation Must Demonstrate Objective Severity and Response

Documentation submitted with prior authorization requests must include objective evidence of severity and treatment response. Specifically, provide baseline and follow‑up Y‑BOCS scores and clinical notes showing inadequate response to prior treatments and adherence to initial criteria.

Baseline and follow‑up Y‑BOCS scores showing severity and change.
Evidence of failed psychopharmacologic trials (see criteria: four trials across ≥2 classes or documented intolerance/interactions).
Evidence of adequate psychotherapy (CBT and/or ERP) combined with medication for at least 12 weeks in the current episode.

Step Therapy

Step Therapy Expectation

Step therapy expectations: dTMS is reserved for treatment‑resistant OCD after adequate trials of psychotherapy (CBT/ERP) plus psychopharmacologic therapy have failed. Prior authorization must document these prior therapy trials and their adequacy.

At least 12 weeks of combined CBT/ERP plus medication during the current episode with <25% improvement on Y‑BOCS prior to dTMS consideration.
Failure to respond to psychopharmacologic agents defined as lack of clinically significant response to four trials representing at least two different agent classes, or documented contraindication/intolerance to agents.

Denial Risk

Continuation / Maintenance Requirements

Continuation/retreatment considerations: continued or repeat dTMS beyond the initial approved course requires documentation that initial‑therapy criteria remain met and that the member experienced a clinically meaningful response. A response is defined as at least a 30% reduction in Y‑BOCS from baseline, with documented duration of response (6 months) when applicable. Maintenance dTMS is considered not medically necessary.

Continued or repeat treatment requires meeting initial dTMS criteria.
Documented response threshold: ≥ 30% reduction in baseline Y‑BOCS score.
Maintenance dTMS is not covered/considered not medically necessary.

Denial Risk

Requests Exceeding Approved Session Maximum — Denial Risk

Requests exceeding the approved session maximum or lacking documented objective response or required prior‑treatment documentation may be denied. Ensure clinical notes, Y‑BOCS scores, psychotherapy and medication history, and device information are included in the submission.

Requests beyond 36 total sessions require strong justification and may be denied.
Absence of baseline or follow‑up Y‑BOCS documentation, inadequate prior treatment trials, or missing referral may lead to denial.