ModifiedCentenePolicy CP.BH.2OO

Transcranial Magnetic Stimulation for Treatment‑Resistant Major Depression

Defines medical necessity, clinical criteria, and coverage stance for repetitive TMS (rTMS), deep TMS (dTMS), and theta burst stimulation (iTBS) for adolescents and adults with treatment‑resistant major depressive disorder for Centene-affiliated plans.

Policy Summary

PayerCentene

PolicyTranscranial Magnetic Stimulation for Treatment‑Resistant Major Depression

Policy CodePolicy CP.BH.2OO

Change TypeMaterial revisions to session limits, modality inclusion, and authorization requirements

Effective Date

Next Review Date

Key ActionObtain prior authorization and document two failed antidepressant trials from two classes, baseline standardized depression score (PHQ‑9 ≥15), and psychiatric evaluation.

SourceLink

POLICY UPDATE CHANGES

Initial number of authorized TMS sessions was changed multiple times in policy history (e.g., from 20 to 30, then language for case-by-case review).

A provision for authorization of up to 6 taper TMS sessions over 3 weeks for certain patients was added.

Policy clarified that oversight of treatment is provided by a licensed psychiatrist except where state scope of practice allows otherwise.

Initial number of sessions changed from 20 to 30 and additional sessions reviewed case-by-case changed from 10 to 6.

Policy statement added that maintenance TMS is not medically necessary due to insufficient evidence.

Up to a total of 30 sessions of Theta Burst Stimulation (TBS) specified; new statement that more than 30 sessions of TBS lacks sufficient evidence.

Expanded criteria to include dTMS for adults ≥18 and new pediatric policy statements for ages 15-17.

Added requirement for documentation of a standardized depression severity rating scale with pre-TMS score documented.

Contraindication added: concurrent esketamine intranasal, ketamine infusion, or other infusion therapies.

MRI-guided theta burst is considered experimental and investigational.

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≤36max sessions per course

≥2required failed trials

PHQ‑9 ≥15severity threshold

15–17adolescent review

30initial sessions (current)

not coveredmaintenance coverage

Coverage Criteria for rTMS/iTBS/dTMS

Maintenance, MRI-guided TBS, and Excess TBS

Not medically necessary / investigational statements for maintenance, MRI-guided TBS, and excess TBS.

ALL of the following

Maintenance treatment with repetitive transcranial magnetic stimulation (rTMS), Theta Burst Stimulation (iTBS), or deep TMS (dTMS) is considered not medically necessary due to insufficient evidence in the published, peer-reviewed literature to support its safety and efficacy.
There is insufficient evidence to support the safety and efficacy of MRI-guided theta burst stimulation (including Stanford Accelerated Intelligent Neuromodulation Therapy [SAINT]) beyond established TMS/TBS techniques; MRI-guided theta burst stimulation is considered investigational/experimental.
There is insufficient evidence to support the safety and efficacy of more than 30 sessions of Theta Burst Stimulation (TBS); >30 sessions of TBS are considered not supported by current evidence and are not authorized.
Requests for maintenance TMS (ongoing scheduled maintenance beyond an acute treatment course) will be denied as not medically necessary; exceptions are not supported by the current evidence base and policy.
Authorization of up to 6 taper TMS sessions over a 3-week period may be considered for members who previously responded to an acute course of TMS and subsequently relapsed within a 6-month period (see Continuation/Retreatment criteria). This is distinct from ongoing maintenance treatment and does not constitute routine maintenance.

Coding and Billing

Referenced CPT/CPT-related 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.
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.

New/HCPCS-like temporary codes for accelerated MRI-guided iTBSCPT

0889T-0892T

Codes added to describe delivery and management of accelerated, high-dose MRI-guided theta-burst stimulation (iTBS).

Removed HCPCS codesHCPCS

GO295

HCPCS code removed from policy coding table (previously included)

Antidepressant trial duration — required duration per trial (inv-18)

Required duration per antidepressant trialEach antidepressant trial must be an adequate course at a recognized therapeutic dose for at least six weeks.

Number of trials requiredFailure of two trials from at least two different antidepressant classes is required (within last 24 months).

Episode timeframe noteTrials should occur during the current depressive episode (and within last 24 months).

Depression severity threshold — PHQ‑9 (or equivalent) score threshold (inv-19)

Severity threshold (adults)PHQ-9 (or equivalent standardized depression scale) score ≥ 15, indicating moderately severe to severe depression.

Provider Actions, Documentation & Prior Authorization

Denial Risk

Maintenance Therapy Denial Risk

Maintenance TMS (rTMS, iTBS, dTMS) is considered not medically necessary. Requests for ongoing/maintenance courses beyond the initial acute treatment course lack sufficient evidence and are likely to be denied.

Maintenance requests for repetitive transcranial magnetic stimulation (rTMS), Theta Burst Stimulation (iTBS), or deep TMS (dTMS) are considered not medically necessary and are at high risk for denial.

Documentation Required

Insufficient Prior Treatment Documentation & Required Documentation

Prior authorization requests must include complete documentation of prior adequate treatment attempts and the selected TMS protocol. Missing or incomplete prior treatment documentation (medication trials, psychotherapy participation, and a standardized depression severity score meeting threshold) risks denial.

Documented failure or intolerance to at least two antidepressant trials from two different classes, each at a recognized therapeutic dose for ≥6 weeks within the last 24 months (or during the current episode) is required.

Definitions and Modalities

Definition of rTMS — repetitive transcranial magnetic stimulation (inv-38)

DefinitionRepetitive transcranial magnetic stimulation (rTMS) is a noninvasive treatment delivering magnetic pulses in repetitive trains to the cerebral cortex to modulate cortical excitability.

Typical parametersIn MDD treatment rTMS is commonly delivered at frequencies ≥10 Hz targeting the dorsolateral prefrontal cortex.

Mechanism noteAn electromagnetic coil placed on the scalp induces focal, patterned current in targeted cortical regions; parameters include location, frequency, intensity, pattern, and duration.

Definition of dTMS — deep TMS using H-coils (inv-39)

DefinitionDeep TMS (dTMS) uses H‑coils to stimulate deeper and wider brain regions compared with standard figure‑8 coils.

Coil effect

Level of Care — Outpatient TMS

TMS Treatment Modalities Included

TMS (rTMS, dTMS, iTBS)

TMS modalities covered: rTMS, dTMS, and iTBS are included modalities; devices must be FDA‑cleared and used according to labeled indications.

dTMS uses H‑coils to stimulate deeper structures (~4 cm); iTBS is a patterned TBS protocol.

TMS (rTMS, dTMS, iTBS, accelerated iTBS/SNT)

Modalities described: Policy describes conventional surface rTMS, deep TMS (dTMS with H‑coils), intermittent theta‑burst stimulation (iTBS), and notes accelerated protocols (e.g., SAINT/SNT) in the evidence discussion; modality-specific evidence and FDA clearances vary and some accelerated or MRI‑guided protocols are considered investigational.

Depth of stimulation for dTMS approximated at 4 cm beneath the cortex; iTBS delivers bursts at higher intra‑burst frequency producing overall lower stimulation frequency.

TMS (rTMS, iTBS/TBS, dTMS)

Session Counts and Visit Limits

rTMS/iTBS/dTMS sessions — typical authorized sessions (inv-50)

Typical authorized sessionsRecommended schedule: five sessions per week for six weeks (approximately 30 sessions) with some policies referencing up to 36 sessions per course and an optional taper of up to 6 sessions.

Course descriptionRequest for initial course commonly reviewed as 30 sessions (historic revisions noted between 20–30); Centene notes a recommended 5/week × 6 weeks schedule.

Taper optionOptional tapered final sessions (up to 6) over 3 weeks may be authorized for qualifying patients, per policy history.

TMS sessions — historical initial course ranges and additional session counts (inv-51)

Historical initial course rangesInitial course historically varied between 20 and 30 sessions in policy revisions.

Additional session counts

Background and Evidence Summary

Major depressive disorder (MDD) is characterized by episodes of depressed mood and functional impairment. Transcranial magnetic stimulation (TMS) refers to noninvasive neuromodulation modalities including repetitive TMS (rTMS), deep TMS (dTMS) using H‑coils to reach deeper cortical structures, and intermittent theta‑burst stimulation (iTBS), a patterned, high‑frequency burst protocol. TMS offers a non‑anesthetic, non‑seizure‑producing alternative to electroconvulsive therapy for treatment‑resistant depression; specific modality selection and parameters (e.g., coil type, frequency, and session schedule) affect therapeutic effect and are addressed in the coverage criteria.

Policy Summary

PayerCentene

PolicyTranscranial Magnetic Stimulation for Treatment‑Resistant Major Depression

Policy CodePolicy CP.BH.2OO

Change TypeMaterial revisions to session limits, modality inclusion, and authorization requirements

Effective Date

Next Review Date

Key ActionObtain prior authorization and document two failed antidepressant trials from two classes, baseline standardized depression score (PHQ‑9 ≥15), and psychiatric evaluation.

SourceLink

On This Page

Adolescent threshold

PHQ-A (modified PHQ-9 for teens) or equivalent score ≥ 15 required for adolescents (ages 15–17) under case-by-case review.

Documentation requirementScore must be documented as part of the clinical record per policy criteria.

Taper sessions authorization — up to 6 taper TMS sessions over 3 weeks (inv-20)

Authorized taper sessionsUp to 6 taper TMS sessions over a 3-week period will be considered for patients with prior response who relapse within 6 months or approaching PHQ‑9 of 9 after >50% improvement.

Eligibility conditionsDocumented prior treatment response (≥50% improvement) with a 6-month duration of response or imminent symptom return as specified in policy.

Review processRequests for taper sessions are reviewed and must include supporting documentation of prior response and current status.

Maximum TBS sessions — policy-specified limit for theta burst stimulation (inv-21)

Maximum TBS sessionsPolicy limit: up to a total of 30 sessions of Theta Burst Stimulation (TBS); requests for >30 sessions are considered unsupported by evidence.

Evidence stancePolicy states insufficient evidence to support safety and efficacy of more than 30 TBS sessions.

Authorization implicationRequests exceeding 30 TBS sessions may be denied per policy guidance.

Documentation that the member participated in an adequate trial of evidence-based psychotherapy (e.g., CBT or IPT) overlapping with medication trials and without significant improvement.

Pre-TMS standardized depression severity score (e.g., PHQ-9 ≥15 or equivalent) must be provided and used to monitor response during treatment.

Complete documentation of the rTMS/iTBS/dTMS protocol to be used (device, parameters, schedule).

Prior Authorization

Required Medication Trials & Prior pharmacologic/augmentation attempts

The member must have failed appropriate pharmacologic and augmentation strategies before TMS will be authorized. Provide clear records of prior medication trials and any augmentation attempts.

Failure of two trials of antidepressants from at least two different antidepressant classes (adequate dose and duration ≥6 weeks) is required.
Documentation of prior augmentation strategies (e.g., adjunctive antipsychotic, lithium, thyroid augmentation, psychostimulant, or other evidence-based augmentation) when attempted should be included.
If intolerance is claimed, documentation must show the nature of intolerance (major adverse interactions or intolerable side effects) and that both criteria for intolerance are met when asserted.

Documentation Required

Therapy trial documentation

Provide documentation that the current depressive episode was treated with psychotherapy and that medication and therapy trials overlapped. Records must show lack of significant improvement despite these treatments.

Evidence of an adequate trial of evidence-based psychotherapy during the current episode (e.g., CBT, IPT) and documentation that this therapy overlapped with antidepressant trials.
Clinical notes showing clinical response or lack thereof, dates and durations of psychotherapy, and clinician rationale for progressing to TMS.
If ECT was attempted or considered contraindicated, provide psychiatrist documentation explaining why TMS is preferred or ECT is contraindicated.

Documentation Required

Standardized scale and protocol documentation

A standardized depression severity scale score (pre‑TMS) and the planned TMS protocol must be included with authorization requests to measure baseline severity and monitor response.

Pre‑treatment standardized rating scale score (e.g., PHQ‑9, PHQ‑A for adolescents, MADRS) demonstrating moderately severe to severe depression (PHQ‑9 ≥15 or equivalent).
Planned rTMS/iTBS/dTMS protocol details: device (FDA‑cleared device name), stimulation parameters, frequency, number of sessions (up to initial limit), and schedule (e.g., 5 days/week × 6 weeks).
Documentation that the provider will monitor and record standardized scale scores throughout the course of treatment.

H‑coils produce a magnetic field with deeper and wider distribution than standard surface coils, affecting both deeper and surface cortical structures.

Indication notedTMS is described as an included modality for adults ≥18 years when clinical criteria are met.

Definition of iTBS — intermittent theta burst stimulation (inv-40)

DefinitionIntermittent theta burst stimulation (iTBS) delivers short bursts of three to five pulses per burst at high intra-burst frequency with a specific interburst interval, producing an overall lower stimulation frequency (commonly ~5 Hz).

Burst structureBursts contain 3–5 pulses delivered at high intra-burst frequency; interburst intervals generate the theta-pattern overall frequency.

Relation to rTMSiTBS is a patterned form of rTMS designed to provide efficient neuromodulation with shorter session durations.

dTMS — further definition (H-coils, ~4 cm depth) (inv-41)

dTMS coilsdTMS is administered using H‑coils that stimulate approximately 4 cm beneath the cortex and also affect surface cortical structures.

Depth estimateApproximate stimulation depth with H‑coils is about 4 cm beneath the cortical surface.

DistributionH‑coils produce a deeper and wider magnetic field distribution than standard figure‑8 coils used for surface TMS.

iTBS (Theta burst TMS) — burst pattern and pulse details (inv-42)

Burst patterniTBS delivers short bursts of three to five pulses per burst at higher intra-burst frequency with a specific interburst interval, producing an overall theta-pattern (commonly 5 Hz).

Pulse count per burstEach burst typically contains 3–5 pulses; sessions employ repeated bursts separated by defined interburst intervals.

Overall frequencyDespite high intra-burst frequency, the interburst timing generates an overall stimulation frequency around 5 Hz.

Theta Burst Stimulation (TBS) — patterned TMS with session limits (inv-43)

DefinitionTheta Burst Stimulation (TBS) is a patterned form of TMS delivering bursts in a theta rhythm; policy specifies up to 30 sessions of TBS.

Session limitPolicy explicitly states insufficient evidence to support more than 30 TBS sessions; requests beyond 30 may be considered unsupported.

Modality relationiTBS is a commonly used TBS protocol; MRI‑guided accelerated TBS protocols (e.g., SAINT) are noted separately and considered investigational in some contexts.

Deep TMS (dTMS) — included for adults ≥18 years (inv-44)

Age applicabilityDeep TMS (dTMS) is included as a modality for adults aged ≥18 years when clinical criteria are met.

Device/coilsdTMS uses H‑coil technology to stimulate deeper/wider regions (approx. 4 cm depth) compared with surface coils.

Policy inclusion notePolicy statements were revised to add dTMS among included TMS modalities for adults in recent updates.

rTMS/iTBS/dTMS inclusion: rTMS, iTBS/TBS, and dTMS are included modalities for adults when clinical criteria are met; MRI‑guided theta burst is considered experimental and investigational and is not included.

Additional sessions historically reviewed ranged from 6–10 (policy revised additional sessions to 6 for case-by-case review).

Taper allowanceTaper sessions up to 6 over 3 weeks were added as a provision for patients with prior response and relapse within 6 months.

TMS sessions (initial authorization) — current initial authorization session count (inv-52)

Current initial authorization countInitial authorization commonly set at 30 sessions (policy language reflects change from earlier 20-session default to 30).

Recommended scheduleApproximate schedule: 5 sessions per week for 6 weeks (documented in policy notes).

Case-by-case review noteInitial counts and requests for additional sessions are subject to case-by-case review per policy history and current criteria.

Optional tapered final sessions — up to 6 optional taper sessions (inv-53)

Optional tapered final sessionsUp to 6 optional taper TMS sessions over a 3-week period may be authorized for qualifying patients with prior response and relapse or approaching PHQ‑9 of 9 after >50% improvement.

Eligibility documentationAuthorization requires documentation of prior response (≥50% improvement) and clinical justification for tapering.

TimingTaper sessions are intended to be delivered over a 3-week period following the initial course or upon relapse as specified.