ModifiedCentenePolicy N/A

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

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

Policy Summary

PayerCentene

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

Policy CodePolicy N/A

Change TypeMaterial revisions to coverage limits, response threshold, device and code additions

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for initial dTMS requests including device and session plan plus baseline Y-BOCS and evidence of prior CBT/ERP and medication trials.

SourceLink

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ModifiedCentenePolicy N/A

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

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Policy Summary

PayerCentene

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

Policy CodePolicy N/A

Change TypeMaterial revisions to coverage limits, response threshold, device and code additions

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for initial dTMS requests including device and session plan plus baseline Y-BOCS and evidence of prior CBT/ERP and medication trials.

SourceLink

POLICY UPDATE CHANGES

Changed the required response threshold for retreatment and continuation from 25% to 30% reduction in baseline Y-BOCS scores.

Increased the maximum authorized sessions for an initial course from 30 to up to 36 sessions (five/week for six weeks plus up to six taper sessions).

Added explicit list of FDA-cleared devices (e.g., Brainsway H7 coil, MagVenture DB80, Magstim Horizon 3.0, NeuroStar).

Added new CPT/HCPCS codes 97014 and 97032.

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

Removed relative contraindications: history of seizures, severe dementia, severe cardiovascular disease, and active suicidal ideation with intent.

up to 36authorized dTMS sessions (initial course)

30%Y-BOCS response threshold

>=18minimum member age

H7dTMS coil type cited

4failed medication trials required

2new billing codes

Coverage Criteria for dTMS (OCD)

Initial Therapy

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

Initial dTMS criteria: Member is >= 18 years; confirmed DSM diagnosis of obsessive-compulsive disorder (OCD); OCD is not part of a presentation with multiple psychiatric comorbidities; inadequate response to CBT/ERP plus pharmacotherapy during the current episode, defined as less than 25% improvement on the Y-BOCS or failure to respond to four trials of agents representing at least two different agent classes (including SSRIs, SNRIs, clomipramine, or atypical antipsychotic augmentation) with adequate duration (at least some trials >=12 weeks); request is for up to 36 sessions; treatment administered using an FDA-cleared device in accordance with labeled indications; direct supervision provided by a licensed psychiatrist except where state scope of practice allows otherwise; and absence of listed contraindications (see policy).

Maintenance and Retreatment

Maintenance and retreatment stance:

Maintenance dTMS is considered not medically necessary due to insufficient peer-reviewed literature to support maintenance treatment.

Retreatment approval: Retreatment will be reviewed on a case-by-case basis by medical leadership and requires that initial dTMS criteria continue to be met, current Y-BOCS > 15, and documented prior treatment response of at least 30% reduction from baseline with a documented 6-month duration of response.30%

Medical director/case-by-case review required

Key Updated Coverage Provisions

Covered when criteria in policy are met, with the following explicitly stated provisions and limits:

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

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

Device examples: Treatment to be provided using FDA-cleared systems (examples listed in policy include Brainsway dTMS H7 coil, MagVenture DB80, Magstim Horizon 3.0, NeuroStar Advanced Therapy).

Substance use remission: Member is not a candidate if there is less than three months of substantiated remission from a substance use disorder.

Contraindications to deep transcranial magnetic stimulation (dTMS) include the presence of conductive or ferromagnetic metallic implants in or near the head or neck within 30 cm of H7 coil placement. Examples specifically listed in the policy are cochlear implants; aneurysm clips or coils; implanted electrodes/stimulators (including deep brain stimulation systems); vagus nerve stimulators; cardiac pacemakers; cardioverter defibrillators; intracardiac lines; medication pumps; bullet fragments; and metallic dyes in tattoos. The policy also excludes other implanted stimulators that use electrical or magnetic signals and any device or implant that could interact with the magnetic field.

The policy explicitly removed several prior "relative contraindication" entries. The items removed from the list include history of seizures, severe dementia, severe cardiovascular disease, and active suicidal ideation with intent.

Maintenance treatment with dTMS for obsessive-compulsive disorder is considered not medically necessary because there is insufficient peer-reviewed literature to support ongoing maintenance use at this time.

Where specific not-medically-necessary language for other scenarios is not provided elsewhere in the document, operational determinations should follow the policy's stated criteria and exclusions; for example, requests that do not meet the policy requirements for age, DSM-confirmed diagnosis, prior adequate trials of CBT/ERP plus pharmacotherapy, or that exceed the authorized session limit may be denied. The policy background and revisions should be consulted for additional context when specific NMN statements are not present.

Billing and Coding

Referenced CPT/HCPCS Codesmixed

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 response threshold — 30% reduction

Response threshold30% reduction from baseline Y-BOCS score for response and retreatment decisions

PurposeUsed to determine prior response to initial dTMS and eligibility for retreatment

Applied toRetreatment and continuation determinations per policy criteria (requires documented 6-month duration of prior response)

Maximum approved sessions (summary)

Maximum approved sessions (initial course)36 sessions

Recommended scheduleFive days per week for six weeks, with an optional six-session taper

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required and Session Limits

Prior authorization is required for initial and continuation courses of deep transcranial magnetic stimulation (dTMS) for OCD. Requests must specify the device model and proposed number of sessions (requests are for up to 36 sessions). Recommended treatment scheduling is five sessions per week for six weeks (30 sessions) with an optional taper of up to six additional sessions; requests that exceed the approved session limit or do not align with recommended scheduling may be denied.

Prior authorization required for initial course and continuation
Specify FDA-cleared device model (e.g., Brainsway H7 coil, Magstim Horizon 3.0, MagVenture DB80, NeuroStar Advanced Therapy)
Maximum request: up to 36 sessions (recommended schedule: 5x/week x 6 weeks = 30 sessions + optional 6-session taper)
Requests exceeding approved session limits or inconsistent schedules risk denial

Documentation Required

Background and Rationale

Obsessive-compulsive disorder (OCD) affects an estimated 2–3% of individuals in the United States. First-line treatment typically combines evidence-based psychotherapy—specifically cognitive behavioral therapy with exposure and response prevention (CBT/ERP)—with pharmacotherapy such as selective serotonin reuptake inhibitors (SSRIs) or clomipramine; many patients require multiple medication trials and augmentation strategies before being considered treatment-resistant. Deep transcranial magnetic stimulation (dTMS), generally delivered using an H7 coil targeting deeper cortical structures including medial prefrontal and anterior cingulate regions, is an FDA-cleared device-based therapy for OCD that is positioned as an add-on option after inadequate response to recommended first-line therapies. Clinical studies and real-world reports commonly show symptomatic improvement emerging near ~18–20 sessions, and policy-specified initial courses are authorized for up to 36 sessions following device-specific, FDA‑cleared protocols.

Key Definitions and Scales

Y-BOCS description

Scale nameYale-Brown Obsessive Compulsive Scale (Y-BOCS)

Items10 clinician-rated items assessing obsessions and compulsions

Score range0 to 40 (each item 0–4)

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

Y-BOCS referenced in literature

Literature referencesGoodman et al., 1989 (development of Y-BOCS) and listed clinical references cite Y-BOCS as standard OCD outcome measure

Use in policy

Level of Care — Outpatient dTMS

Outpatient dTMS (additional literature-supported nodes)

Level of care—outpatient considerations: Outpatient dTMS delivered per FDA-cleared device protocol; candidates meet the policy's clinical admission criteria (adult, DSM-confirmed OCD, baseline Y-BOCS in moderately severe to severe range, failed adequate CBT/ERP plus pharmacotherapy).

Continued treatment indicators: Continued outpatient treatment requires documented clinical response or ongoing clinically meaningful improvement on Y-BOCS, absence of emergent contraindications, and that maximum initial course (up to 36 sessions) has not been exceeded.

Device and Treatment Modality Details

dTMS (H7 coil)

H7 coil dTMS modality: Use of H7-coil deep TMS targeting medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC); described as stimulating deeper brain regions and used in trials demonstrating symptomatic improvement; typical schedules five times/week for six weeks with optional tapering sessions.

Deep TMS device-based therapy

Device-based therapy—deep TMS: Deep TMS is provided using FDA-cleared TMS systems; policy references multiple cleared systems (Brainsway, Magstim Horizon 3.0, MagVenture TMS Therapy System, NeuroStar Advanced Therapy) as examples that align device-based therapy to labeled indications.

Session Limits and Visit Frequency

dTMS sessions (session cap)

Session cap36 sessions

ContextApproved for initial dTMS course (recommended five/week for six weeks plus optional taper) per updated policy

Coding/authorization impactPrior authorization required for up to 36 sessions

dTMS sessions (redundant entry)

Session cap (redundant inventory entry)36 sessions

Representation noteIncluded to mirror duplicate inventory listings ensuring consistent session limit across sections

Recommended schedule

Policy Summary

PayerCentene

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

Policy CodePolicy N/A

Change TypeMaterial revisions to coverage limits, response threshold, device and code additions

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for initial dTMS requests including device and session plan plus baseline Y-BOCS and evidence of prior CBT/ERP and medication trials.

SourceLink

On This Page

>=3 months remission

Policy change noteFrequency changed from 30 to 36 approved sessions in updated policy

Required Documentation (Diagnosis, Y-BOCS, Response Duration)

Documentation must include DSM-based diagnosis and standardized symptom severity scoring. For initial requests, provide baseline Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. For retreatment requests, provide evidence of prior response and duration of benefit.

DSM-based diagnosis of OCD
Baseline Y-BOCS score (0–40) for initial authorization
For retreatment: documentation of prior treatment response (≥30% reduction from baseline) with a documented 6-month duration of response
Follow-up Y-BOCS scores as requested by reviewer

Step Therapy

Step Therapy Expectation and Operational Note

Step therapy expectations are described (adequate trials of CBT/ERP and multiple pharmacologic trials are required), but no explicit operational step sequence or automated step edits are provided in the policy text. Providers must document prior adequate CBT/ERP and pharmacologic trials meeting the policy criteria when submitting authorization requests.

Policy requires prior adequate CBT/ERP and pharmacologic trials (e.g., ≥4 trials across ≥2 drug classes including SSRIs/SNRIs or clomipramine, with at least two adequate SSRI/SNRI trials)
No explicit step-by-step operational sequence is defined in this policy — authorization review relies on documented prior treatments rather than an automated step edit

Denial Risk

Denial Triggers and Risks

Denial risks include requests for members under age 18, non‑DSM OCD diagnoses or presentations with multiple severe psychiatric comorbidities, insufficient prior trials of CBT/ERP and medications, missing baseline or follow-up Y-BOCS documentation, requests exceeding session limits, or lack of required device specification and supervision documentation.

Member < 18 years old: deny
Diagnosis not meeting DSM criteria for OCD or presence of disqualifying psychiatric comorbidities: deny
Insufficient documentation of prior adequate CBT/ERP and pharmacologic trials (per policy definition): deny
Missing baseline Y-BOCS or lack of documented prior response/duration for retreatment requests: deny
Requests exceeding 36 sessions or inconsistent with recommended scheduling: may be denied
Lack of device identification (FDA-cleared device) or absent supervision documentation: may be denied

Referenced in policy as the standard baseline and follow-up severity measure for dTMS decision-making

Supporting sourcesAPA and multiple TMS/OCD clinical reviews and device approvals list Y-BOCS in references

Five days/week for six weeks with optional six-session taper