ModifiedCentenePolicy CP BH.2OI

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

Medical necessity and coverage criteria for initial, maintenance, and retreatment use of deep transcranial magnetic stimulation (dTMS) to treat obsessive-compulsive disorder (OCD) for Centene-affiliated plans.

Policy Summary

PayerCentene

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

Policy CodePolicy CP BH.2OI

Change TypeMaterial updates to session limits, retreatment thresholds, and contraindications

Effective Date

Next Review Date

Key ActionSubmit prior authorization documenting age ≥18, DSM-confirmed OCD, failed adequate CBT/ERP plus multiple medication trials, Y-BOCS scores, and requested sessions (up to 36).

SourceLink

POLICY UPDATE CHANGES

Changed the number of allowable sessions for an initial request to up to 36 sessions with an optional six-session taper.

Updated response thresholds for retreatment/continuation criteria from 25% to 30% reduction in baseline Y-BOCS scores.

Added a specific contraindication: no active suicidal ideation with intent.

Added CPT/HCPCS codes 97014 and 97032 to the policy coding list.

Changed the maximum approved number of sessions from 30 to 36 with a recommended schedule of five days a week for six weeks and an optional six taper sessions.

Removed several relative contraindications including history of seizures, severe dementia, severe cardiovascular disease, and active suicidal ideation with intent from the contraindication list.

Replaced 'substance abuse at time of treatment' with 'less than three months of substantiated remission from a substance use disorder' in contraindication language.

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Coverage Criteria for dTMS (OCD)

Initial Therapy

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

Initial dTMS medical necessity: Member is >=18 years old; confirmed DSM diagnosis of obsessive-compulsive disorder (OCD); OCD is not part of a presentation with multiple psychiatric comorbidities; Y-BOCS indicates moderately severe to severe OCD (per policy severity bands); less than 25% improvement on Y-BOCS from prior therapy during the current episode; failure to respond to adequate trials of CBT/ERP plus multiple pharmacologic trials defined as lack of clinically significant response in the current episode to four trials across at least two drug classes (including SSRIs, SNRIs, clomipramine, or atypical antipsychotic augmentation); treatment will be delivered using an FDA-cleared device (examples: Brainsway H7 coil, MagVenture cool DB80 coil, Magstim Horizon 3.0, NeuroStar).N/A

Request up to 36 sessions (recommended schedule: 5/week for 6 weeks with optional 6-session taper).

Maintenance and Retreatment

Policy position on maintenance treatment and criteria for retreatment:

Maintenance dTMS for OCD is considered not medically necessary due to insufficient peer-reviewed literature to support maintenance treatment.N/A

Retreatment will be reviewed when initial dTMS criteria continue to be met; current Y-BOCS is >15 with symptom worsening; and prior treatment response documented at least 30% reduction from baseline Y-BOCS with a documented approximately 6-month duration of response.30% reduction

Documented durability of response required.

Coverage criteria highlights

Covered when ALL of the following are met (as specified elsewhere in the policy):

Session limit: Request is for up to 36 sessions (recommended schedule: five days per week for six weeks, with an optional six-session taper).<=36 sessions

Revised from 30 sessions

Supervision: Direct supervision of treatment is provided by a licensed psychiatrist except where state scope of practice acts allow other provider types to supervise.

Supervisory language clarified

Substance use disorder remission: No active substance use disorder; policy specifies that less than three months of substantiated remission from a substance use disorder is relevant to contraindication determinations.>=3 months remission preferred

Replaced prior vague wording regarding substance abuse at time of treatment

Exclusion and contraindication conditions include presence of conductive or ferromagnetic implants or other magnetic-sensitive metal implanted or embedded in the head or neck within 30 cm of the dTMS H‑7 coil placement (other than dental fillings). Examples listed in the policy include cochlear implants, aneurysm clips or coils, stents, bullet fragments, and metallic tattoo dyes. The policy also specifically lists implanted electrodes/stimulators (e.g., deep brain stimulation systems) and other implanted devices that use electrical or magnetic signals (for example, cardiac pacemakers) as contraindications to dTMS treatment.

The policy removed several prior relative contraindications from the list, including history of seizures, severe dementia, and severe cardiovascular disease; it also removed active suicidal ideation with intent from the contraindication list in the update. The policy continues to require assessment for other active mental health disorders and substance use considerations when determining appropriateness for dTMS.

Maintenance treatment with dTMS for obsessive‑compulsive disorder is stated as not medically necessary because there is insufficient peer‑reviewed literature to support ongoing maintenance use of dTMS for OCD at this time.

The excerpt provided does not present an expanded list of additional explicit 'not medically necessary' conditions beyond the statement that maintenance dTMS is not medically necessary. The policy update did, however, remove several previously listed relative contraindications (see revisions) which may influence determinations in specific cases and should be reviewed in the full policy when making coverage decisions.

Billing and Coding

Referenced CPT/HCPCS 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.
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.

Added CPT/HCPCS codesCPT

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

SubclinicalY-BOCS total score < 8

MildY-BOCS total score 8–15

ModerateY-BOCS total score 16–23

SevereY-BOCS total score 24–31

ExtremeY-BOCS total score 32–40

Maximum sessions

Maximum authorized sessions (initial course)36 sessions (includes optional 6-session taper)

Provider Requirements and Authorization

Prior Authorization

Prior Authorization — Initial Treatment

Prior authorization is required for initial dTMS treatment for OCD. Requests must document the member is ≥18 years old, has a confirmed DSM diagnosis of obsessive-compulsive disorder, and meet the policy's required prior treatments and clinical criteria. Authorization requests should specify the total number of sessions requested (requests may be for up to 36 sessions) and the proposed treatment schedule.

Request must document age ≥18 and DSM-confirmed diagnosis of OCD.
Include baseline Y-BOCS score and prior treatment history (see required prior treatments).
Specify requested number of sessions (maximum 36) and proposed schedule (recommended 5x/week for 6 weeks with optional up to 6 taper sessions).
Direct supervision by a licensed psychiatrist (or as allowed by state scope of practice) must be documented.

Denial Risk

Denial Risk — Maintenance and Contraindications

Background and Context

Obsessive‑compulsive disorder (OCD) affects roughly 2–3% of individuals in the United States. First‑line treatment typically includes pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) combined with cognitive behavioral therapy incorporating exposure and response prevention (CBT/ERP). Deep transcranial magnetic stimulation (dTMS) for OCD uses an H‑7 coil on an FDA‑cleared device to stimulate deeper medial prefrontal and anterior cingulate regions; clinical trials and real‑world reports show treatment effects often emerge within approximately 18–20 sessions. When covered, dTMS is administered using an FDA‑cleared system (examples cited in the policy include the Brainsway H‑7 coil, MagVenture, Magstim, and NeuroStar) and is intended as a treatment option after failure of adequate CBT/ERP and multiple adequate pharmacologic trials.

Definitions

Y-BOCS

Scale description10-item clinician-rated scale measuring obsessions and compulsions; items scored 0–4; total 0–40

Score rangeTotal score range 0–40

Severity interpretationSeverity bands map total score to Subclinical, Mild, Moderate, Severe, Extreme

dTMS (definition)

DefinitionDeep transcranial magnetic stimulation (dTMS) is an FDA-cleared neuromodulation therapy for OCD using specialized TMS systems (examples cited: Brainsway, Magstim, MagVenture, NeuroStar)

Device exampleBrainsway Deep TMS System (H7 coil) referenced in policy

Regulatory status

Level of Care Criteria

Treatment Modalities

dTMS (H7 coil)

dTMS (H7 coil) modality specification: dTMS must be administered using an FDA-cleared device in accordance with labeled indications; example device referenced is the Brainsway dTMS H7 coil (device stimulates deeper regions including ACC and mPFC).

Direct supervision required as specified in policy.

dTMS

dTMS device clearance: Use of FDA-cleared dTMS systems is required (examples cited in policy: Brainsway, Magstim, MagVenture, NeuroStar).

Devices cited in references.

Visit Limits and Scheduling

dTMS sessions (with optional taper)

Authorized sessions per course36 sessions (includes optional 6-session taper)

Recommended schedule5 sessions per week × 6 weeks

Taper optionOptional 6 taper sessions included within the 36-session limit

dTMS sessions

Per-course session limit36 sessions

Scheduling noteRecommended frequency 5x/week for 6 weeks

Authorization expectationRequests should document the number of sessions up to the 36-session limit

Policy Summary

PayerCentene

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

Policy CodePolicy CP BH.2OI

Change TypeMaterial updates to session limits, retreatment thresholds, and contraindications

Effective Date

Next Review Date

Key ActionSubmit prior authorization documenting age ≥18, DSM-confirmed OCD, failed adequate CBT/ERP plus multiple medication trials, Y-BOCS scores, and requested sessions (up to 36).

SourceLink

On This Page

Maintenance dTMS is not covered — requests for ongoing/maintenance treatment should be denied per policy.
Contraindications that may lead to denial include presence of metallic or magnetic-sensitive implants within 30 cm of coil (e.g., cochlear implants, implanted electrodes, aneurysm clips/coils, stents, pacemakers, deep brain stimulators, vagus nerve stimulators, bullet fragments, certain metallic tattoo dyes), cardiac devices (pacemaker, cardioverter defibrillator), intracardiac lines, medication pumps, and similar implanted stimulators.
Additional denial risks: known non-adherence to prior OCD treatment, less than three months of substantiated remission from a substance use disorder, and presence of other primary mental health disorders (e.g., psychotic disorders, primary mood disorders) where OCD is not the primary diagnosis.

Step Therapy

Exceeding Session Limits

Requests exceeding the policy's session limits or not following the recommended schedule may be denied. Authorization supports up to 36 sessions for an initial course; requests beyond this amount require clear documentation of exceptional clinical necessity and will be reviewed against retreatment criteria.

Maximum approved initial course: up to 36 sessions (recommended schedule: 5 sessions per week for 6 weeks, optional up to 6 taper sessions included in the 36).
Requests for more than 36 sessions or for maintenance/ongoing treatment are not routinely approved and may be denied without strong supporting documentation.
Retreatment beyond an initial course will be reviewed only if initial criteria continue to be met, previous response was clinically meaningful (≥30% improvement with ≥6 months duration of response), and current symptoms have worsened (Y-BOCS >15).

Step Therapy

Required Prior Treatments

Prior to authorization, the policy requires documented failure of recommended first-line treatments. The request must include evidence of adequate trials of both psychotherapy and pharmacotherapy as specified below.

Documented failure to respond to an adequate course of Cognitive Behavioral Therapy (CBT) and/or Exposure and Response Prevention (ERP) during the current episode.
Documented failure of multiple medication trials: lack of clinically significant response to four trials of psychopharmacologic agents representing at least two different agent classes (including trials with SSRIs, SNRIs, clomipramine, and/or atypical antipsychotic augmentation) with adequate dose/duration (generally ≥12 weeks per trial or as clinically appropriate).
At least two medication trials should have been administered as adequate mono- or poly-drug therapy at standard therapeutic doses.
If the member is unable to take standard agents due to intolerance, document trials demonstrating inability to tolerate four distinct agents with differing side effects, or other documented contraindications to pharmacotherapy.