CurrentCignaPolicy EN0383

Transcranial Magnetic Stimulation (TMS)

Defines Cigna coverage policy for various TMS modalities (rTMS, dTMS) for treatment of major depressive disorder and obsessive-compulsive disorder, including initial and repeat courses, exclusions (maintenance, other indications), experimental protocols, and associated CPT/HCPCS codes.

Policy Summary

PayerCigna

PolicyTranscranial Magnetic Stimulation (TMS)

Policy CodePolicy EN0383

Change TypeAnnual review — no clinical changes (3/15/2026)

Effective Date3/15/2026

Next Review Date3/15/2027

Key ActionDocument psychotherapy and medication trial history, administer and record validated depression/OCD rating scales, and confirm use of an FDA-cleared device when requesting TMS coverage.

SourceLink

POLICY UPDATE CHANGES

Annual Review 3/15/2026: No clinical policy statement changes.

Annual Review 3/15/2025: Revised the policy statement for TMS for MDD and revised the policy statements for repeat TMS for MDD and OCD.

Focused Review 11/15/2024: No clinical policy statement changes.

Annual Review 3/15/2024: No clinical policy statement changes.

2Primary covered indications (MDD, OCD)

30-36Initial course treatments (typical)

>=15Minimum age MDD

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40+Conditions listed as not proven/investigational

SeveralFDA device identifiers cited

Coverage Summary

This policy (Cigna coverage criteria EN0383, effective 2026-03-15) addresses Transcranial Magnetic Stimulation (TMS) modalities for neuropsychiatric treatment. The primary covered indications are initial and repeat courses of TMS for major depressive disorder (MDD) (age ≥ 15) and deep TMS for obsessive-compulsive disorder (OCD) (age ≥ 18). The typical acute course size described is 30–36 treatments administered in an outpatient setting. The policy’s current coverage stance is mixed: initial and repeat TMS for MDD and dTMS for OCD are described as medically necessary when specific clinical criteria are met, while other uses or protocols are considered not medically necessary or experimental. Annual review dated 2026-03-15 reports no clinical policy statement changes for this review cycle.

Key thresholds

Initial course size30-36 treatments (typical acute course)

Antidepressant trial duration (adult/adolescent)>= 4 weeks at adequate therapeutic dose (or documented intolerance/contraindication)

OCD pharmacotherapy trial duration>= 8 weeks at adequate therapeutic dose (or documented intolerance/medical contraindication)

Repeat TMS response threshold (MDD)> 50% improvement on a standard depression rating scale at end of most recent course

Repeat dTMS response threshold (OCD)> 30% improvement on Y-BOCS at end of most recent course

Maintained improvement period required for repeat course>= 2 months of maintained improvement after the most recent course

Medical-Necessity Criteria

Initial TMS for Major Depressive Disorder (MDD)

An initial regimen (i.e., 30–36 treatments) of transcranial magnetic stimulation (TMS) administered in an outpatient office setting using a U.S. Food and Drug Administration (FDA)–approved device is considered medically necessary for major depressive disorder (MDD) when ALL of the following criteria are met:

ALL of the following

age 15 years or older
diagnosis of major depressive disorder (unipolar), moderate-to-severe, single or recurrent episode or acute relapse, without psychosis, as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
During the current episode of depression, ALL of the following must be met:
- an adequate trial of an evidence-based psychotherapy known to be effective in the treatment of major depressive disorder, without significant improvement in depressive symptoms

Clinical Statements & Device Guidance

Coverage-related clinical statements and device usage guidance (narrative criteria)

Policy summarizes when TMS is considered evolving/accepted or investigational based on FDA approval and evidence:

TMS for obsessive-compulsive disorder (OCD) is evolving into an accepted treatment option when using FDA-cleared devices for adult individuals who have failed to receive satisfactory improvement from previous pharmacotherapy.

FDA cleared devices listed in policy

Treatment-resistant OCD is defined as satisfactory trials of first-line treatments without adequate response, usually defined by reduction in Y-BOCS score >= 25% from baseline.Y-BOCS reduction >= 25%

Only an FDA approved device should be used to administer TMS for OCD; studies using non-FDA-approved devices are inconclusive and not recommended.

Summary — sTMS for acute treatment of migraine with aura: Single-pulse TMS (sTMS) devices (e.g., Cerena/SpringTMS and sTMS mini) have received FDA de novo/510(k) clearances for the acute treatment of migraine headache with aura and for some devices expanded clearance including adolescents (age ≥12) and adults. The pivotal randomized, sham‑controlled trial (Lipton et al., 2010) formed the basis for FDA clearance: among subjects treating an attack of migraine with visual aura, the trial reported a significantly greater pain‑free rate at 2 hours (39% sTMS vs 22% sham, p=0.018) and sustained pain‑free responses at 24 and 48 hours in favor of sTMS. Trial limitations noted include a high dropout rate during screening/verification phases, potential for unblinding, and variable timing of treatment administration. These device clearances and the Lipton 2010 RCT provide the primary regulatory and randomized evidence supporting sTMS as an option for acute treatment of migraine with aura, but additional randomized trials were recommended to better define optimal dosing and durability.

Coding

Considered Medically Necessary when criteria met (CPT)CPTCovered

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

Considered Not Medically Necessary (HCPCS/CPT Category III / Temp codes)CPTNot Covered

0997T

Precuneus magnetic stimulation; treatment planning using magnetic resonance imaging-guided neuronavigation to determine optimal location, dose, and intensity for magnetic stimulation therapy, derived from evoked potentials from single pulses of electromagnetic energy recorded by 64-channel electroencephalogram, including automated data processing, transmission, analysis, generation of treatment parameters with review, interpretation, and report

0998T

Precuneus magnetic stimulation; personalized treatment delivery of magnetic stimulation therapy to a prespecified target area derived from analysis of evoked potentials within the precuneus, utilizing magnetic resonance imaging-based neuronavigation, with management, per day

Considered Experimental/Investigational/Unproven (Category III / Temp codes)CPTExperimental

0889T	Personalized target development for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation derived from a structural and resting-state functional MRI, including data preparation and transmission, generation of the target, motor threshold-starting location, neuronavigation files and target report, review and interpretation
0890T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including target assessment, initial motor threshold determination, neuronavigation, delivery and management, initial treatment day
0891T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, subsequent treatment day
0892T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, subsequent motor threshold redetermination with delivery and management, per treatment day

FDA device identifiers and manufacturers (examples)mixed

K243539	Apollo TMS Therapy System — Mag & More GmbH
K183303	BrainsWay Deep TMS System — BrainsWay Ltd.
K230657	BTL-99-OC — BTL Industries Inc.
K221129	CloudTMS for OCD — TeleEMG, LLC
K243869	Horizon TMS Therapy System / Horizon Inspire (Magstim) — Magstim Company, Ltd.
K193006	MagVenture TMS Therapy — Tonica Elektronik
K212289	NeuroStar TMS Therapy System — Neuronetics, Inc.

FDA product codesmixed

OBP	FDA product code listed in policy
QCI	FDA product code listed in policy

Devices FDA-cleared/approved for specific indications (examples)mixed

Cerena / SpringTMS	single-pulse TMS (sTMS) device cleared/de novo and 510(k) for acute treatment of migraine with aura; sTMS mini and SpringTMS cleared for acute/prophylactic migraine indications including adolescents and adults
SAVI Dual	SAVI Dual Migraine Therapy device — 510(k) approval for acute and prophylactic treatment of migraine in adolescents (age ≥12) and adults (May 16, 2023)
BrainsWay iTBS	BrainsWay Deep TMS System with iTBS — 510(k) for treatment of depressive episodes in adults who failed prior antidepressants
Mag Vita TBS (Cool-B70)	MagVita TMS Therapy System with Theta Burst Stimulation (Cool-B70) — 510(k) for MDD in adults who failed prior antidepressants
Magnus Neuromodulation System Model 1001K (MNS)	Example FDA-cleared device that utilizes SAINT protocol; 510(k) clearance Sept 1, 2022 for treatment of MDD in adults who failed prior antidepressant medication

Provider Actions & Billing Impact

Documentation Required

Document psychotherapy trial

Document that the patient had an adequate trial of evidence-based psychotherapy (e.g., weekly sessions for at least 12 weeks) during the current episode of depression without significant improvement. Include dates, provider(s), frequency, and clinical response in the record submitted with prior authorization or claims.

Documentation Required

Depression / OCD rating scales

Use validated depression and OCD rating scales at baseline and at the end of the initial and each subsequent course of TMS to document clinical response.

Examples: PHQ-9
HAM-D (Hamilton Depression Rating Scale)
MADRS (Montgomery–Åsberg Depression Rating Scale)
Y-BOCS (Yale-Brown Obsessive Compulsive Scale)

Background & Evidence Summary

Background — TMS modalities and FDA context: Transcranial magnetic stimulation is a noninvasive neuromodulation technique. The most commonly used approaches are surface repetitive TMS (rTMS), which typically targets the left dorsolateral prefrontal cortex (DLPFC) using a figure‑of‑eight coil and reaches about ~2 cm below the cortical surface, and deep TMS (dTMS), which uses H‑coils (contained in a helmet) designed to stimulate deeper structures (reported up to ~6 cm) and larger cortical areas. A standard acute outpatient course is described as 30–36 sessions (one session per day over ~4–6 weeks, with possible tapered sessions). Multiple devices have received FDA 510(k) or de novo clearances for specified indications (examples cited include NeuroStar, BrainsWay dTMS, MagVita TBS systems), and FDA regulatory status is referenced as part of device‑specific coverage guidance; however, coverage decisions also depend on meeting the policy’s clinical criteria.

Evidence/Study	Key finding
dTMS response rate (meta-analysis Nov 2015)	Overall weighted response rate 60% (n=94) after acute high-frequency dTMS sessions; mean weighted effect size d=2.04 (95% CI: 1.53-2.55) compared to baseline HDRS in included studies
Carmi et al. 2019 (deep TMS for OCD)	RCT n=100: active dTMS showed greater Y-BOCS reduction vs sham (difference 2.8 points, p=0.01); full response (≥30% reduction) 38.1% vs 11.1% (p=0.003)
Lipton et al. 2010 (sTMS for migraine with aura)	RCT: pain-free at 2 hours 39% sTMS vs 22% sham (p=0.018); sustained pain-free at 24h 29% vs 16% (p=0.0405)
Brunoni et al. 2017 (network meta-analysis)	Network meta-analysis of 81 RCTs (n=4233) found several modalities (pTMS, bilateral, HF, TBS, LF) superior to sham but imprecision and heterogeneity prevented definitive superiority claims
Theta-burst safety review (Oberman et al. 2011)	Systematic review of 67 studies (n=1040) reported one seizure and various mild adverse events; heterogeneity precluded establishing safety guidelines
nTMS evidence summary (Raffa et al. 2019)	Meta-analysis of 8 studies (n=1,233) suggests nTMS motor mapping may reduce postoperative new permanent motor deficits and increase gross total resection rates; limited by lack of RCTs and heterogeneity

Definitions / terminology

Failed antidepressant trialEither use at adequate therapeutic doses for at least four weeks with no significant reduction in symptoms, or documented intolerance/medical contraindication.

Failed psychopharmacologic trial (OCD)Either use at adequate therapeutic doses for at least eight weeks with no significant reduction in OCD symptoms, or documented intolerance/medical contraindication.

Treatment-resistant OCD

Medicare Determinations

Effective Date	Name	Number	Type
2022-01-06	Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder	L36469	LCD
2020-10-01	Transcranial Magnetic Stimulation (TMS)	L33398 (DL33398)	LCD
2019-12-01	Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder	L37086 / L37088	LCD
2022-06-09	Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder	L34869	LCD
2020-07-30	Transcranial Magnetic Stimulation (TMS)	L34641	LCD

Revision History

3/15/2026annual_reviewLatest

Annual Review 3/15/2026: No clinical policy statement changes. (Non-material)

3/15/2025annual_review

Annual Review 3/15/2025: Revised the policy statement for TMS for MDD and revised the policy statements for repeat TMS for MDD and OCD. (Material)

11/15/2024focused_review

Focused Review 11/15/2024: No clinical policy statement changes. (Non-material)

Policy Summary

PayerCigna

PolicyTranscranial Magnetic Stimulation (TMS)

Policy CodePolicy EN0383

Change TypeAnnual review — no clinical changes (3/15/2026)

Effective Date3/15/2026

Next Review Date3/15/2027

Key ActionDocument psychotherapy and medication trial history, administer and record validated depression/OCD rating scales, and confirm use of an FDA-cleared device when requesting TMS coverage.

SourceLink

On This Page

validated depression monitoring scales are administered at the beginning and at the end of the initial and each subsequent course of TMS

Document scale name(s) and scores in the medical record.

Failure of an antidepressant medication trial is defined as EITHER of the following:

use of an antidepressant medication at adequate therapeutic doses for at least four weeks with no significant reduction in depressive symptoms
use of an antidepressant medication with documented intolerance or medical contraindication

Antidepressant trial requirements by age

for an adult age 18 years or older: failure of two or more trials of antidepressant medications from two separate classes of antidepressant medications
Document agents, doses, and duration.
for an adolescent age 15–17: failure of two trials of antidepressant medications
Document agents, doses, and duration.

Repeat TMS for Major Depressive Disorder (MDD)

Repeat transcranial magnetic stimulation (TMS) (i.e., 30–36 treatments) administered in an outpatient office setting for a recurrence or acute relapse of major depressive disorder is considered medically necessary when ALL of the following criteria are met:

ALL of the following

individual had more than a 50% improvement as evidenced by one or more standard rating scales for depression at the end of the most recent course of TMS
Specify scale(s) and score change in documentation.
improvement has been maintained for at least two months after the most recent course of TMS
Document longitudinal follow-up and stability of response.

Initial deep TMS (dTMS) for Obsessive–Compulsive Disorder (OCD)

An initial regimen (i.e., 30–36 treatments) of deep transcranial magnetic stimulation (dTMS) administered in an outpatient office setting using a U.S. FDA–approved device for obsessive–compulsive disorder (OCD) is considered medically necessary when ALL of the following criteria are met:

ALL of the following

age 18 years or older
diagnosis of obsessive–compulsive disorder (OCD) as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
Failure of psychopharmacologic medication trials
- failure of two or more trials of psychopharmacologic medications for the treatment of OCD
  A failed trial is defined as EITHER: use of a psychopharmacologic medication at adequate therapeutic doses for at least eight weeks with no significant reduction in OCD symptoms, OR use of a psychopharmacologic medication with documented intolerance or medical contraindication. Document agents, doses, and duration.
an adequate trial of an evidence-based psychotherapy known to be effective in the treatment of OCD, without significant improvement in OCD symptoms
Examples include cognitive behavioral therapy with exposure and response prevention; document type and duration.
the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) is administered at the beginning and at the end of the initial and each subsequent course of TMS
Document baseline and post-course Y-BOCS scores.

Repeat deep TMS (dTMS) for Obsessive–Compulsive Disorder (OCD)

Repeat deep transcranial magnetic stimulation (dTMS) (i.e., 30–36 treatments) administered in an outpatient office setting for a recurrence or acute relapse of OCD is considered medically necessary when ALL of the following criteria are met:

ALL of the following

individual had more than a 30% improvement as evidenced by Yale–Brown Obsessive Compulsive Scale (Y-BOCS) at the end of the most recent course of TMS
Document percent improvement and both pre- and post-treatment Y-BOCS scores.
improvement has been maintained for at least two months after the most recent course of TMS
Document maintenance of response over time.

Not Medically Necessary

Transcranial magnetic stimulation (TMS) is considered not medically necessary in the following situations:

ANY of the following

TMS used as a maintenance therapy
Maintenance (continuous or scheduled ongoing sessions after an initial and any repeat acute course) is not covered.
TMS for any other indication not otherwise specified as covered in this policy, including but not limited to migraine headaches
Other neuropsychiatric or neurologic indications are not established as medically necessary under this policy unless specified in the applicable policy statements.

Experimental, Investigational or Unproven

The following treatment protocols and applications of TMS are considered experimental, investigational, or unproven and therefore not covered:

ANY of the following

Accelerated treatment protocols, including but not limited to Theta Burst Stimulation (TBS)
Clinical benefit and long-term outcomes remain unproven for accelerated schedules compared with standard protocols.
Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT)
Considered investigational/experimental.
Stanford Neuromodulation Therapy (SNT)
Considered investigational/experimental.
Other accelerated or novel investigational TMS protocols not specifically listed above
Include protocols such as high-dose accelerated protocols delivered over multiple sessions per day and any MRI-guided personalized accelerated approaches unless FDA-cleared and supported by sufficient evidence.

TMS for Other Neuropsychiatric Indications (Investigational)

TMS for other neuropsychiatric indications not otherwise established in this policy is considered investigational (not medically necessary). The following non-exhaustive list captures examples that are considered investigational or unproven under this policy:

ANY of the following

TMS for treatment of post-traumatic stress disorder (PTSD)
TMS for bipolar disorder (including bipolar depression) except when comorbid unipolar MDD criteria met per this policy and plan coverage permits
TMS for generalized anxiety disorder, panic disorder, or other anxiety-spectrum disorders
TMS for cognitive disorders (including Alzheimer's disease and other dementias)
TMS for substance use disorders (including nicotine dependence)
TMS for movement disorders (e.g., Parkinson disease, dystonia)
TMS for traumatic brain injury or post-concussive syndromes
TMS for chronic pain conditions other than specifically authorized indications
TMS for pediatric indications outside the specified covered age ranges
Any other neuropsychiatric or neurologic indication where there is insufficient evidence of efficacy and safety

sTMS for migraine with aura (acute treatment)

Summary of FDA indication and evidence supporting acute treatment for migraine with aura:

Cerena / Spring sTMS device is FDA cleared/approved for acute treatment of migraine headache with aura (prescription device; patient self-administered).

sTMS mini 510(k) approval noted

sTMS mini has 510(k) approval for acute treatment of migraine with aura and designed for home/office use.

SpringTMS and SAVI Dual devices received approvals for acute and prophylactic treatment of migraine in adolescents (age >=12) and adults per cited FDA clearances.>= 12 years

Randomized trial (Lipton et al., 2010) demonstrated significant pain-free response at 2 hours and sustained pain-free response at 24 and 48 hours for sTMS versus sham in migraine with aura; limitations include high dropout and varied timing of treatment.

Other TMS modalities — evidence and status

Descriptions and evidence summaries for accelerated, bilateral, high-dose, multi-locus, priming, and theta-burst TMS:

Accelerated TMS (aTMS): multiple sessions per day; evidence conflicting, small studies, short follow-up — investigational for most indications.

Studies small, heterogeneous; not established

Bilateral TMS: sequential bilateral stimulation has not consistently shown superiority over unilateral rTMS; evidence does not support routine use over unilateral rTMS.

High-dose TMS: proposed to deliver substantially more pulses per session; evidence limited to case series and reports — investigational.

Multi-locus TMS (mTMS): investigational; lacks clinical trials.

Priming TMS (pTMS): proposed technique with limited/small studies — investigational.

Theta burst stimulation (TBS): Theta burst stimulation (TBS — iTBS/cTBS): emerging modality; some FDA-cleared devices for MDD when prior antidepressants failed; evidence for many other indications is limited.

Safety concerns and heterogeneity; Oberman safety review

Documentation Required

Medication trial documentation

When documenting medication trials include: medication name(s), dose(s), start and stop dates, duration at adequate therapeutic dose (≥4 weeks for antidepressants in depression; ≥8 weeks for OCD psychopharmacologic agents), evidence of adherence, and documentation of intolerance or medical contraindication when applicable.

Billing Rule

Course length and setting

Course length and setting must match policy (initial and repeat regimens typically 30–36 treatments) and be provided in an outpatient office setting. Include CPT codes when submitting claims.

Affected CPT codes: 90867, 90868, 90869
Typical outpatient regimen: 30–36 treatments

Denial Risk

Not covered uses / experimental protocols

Not covered uses and experimental protocols will increase denial risk. Do not submit PA/claims for maintenance therapy, migraine indications, or accelerated/novel protocols that the policy designates as experimental.

Affected codes: 0997T, 0998T, 0889T–0892T
Examples: maintenance therapy, migraine treatment, accelerated protocols (e.g., TBS/SAINT/SNT)

Documentation Required

Provider qualifications

Ensure treating clinicians meet required qualifications and training for TMS delivery. Documentation of clinician credentials and specialized TMS training should be included with PA/claims.

Documentation Required

Confirm treatment‑resistant OCD prior to TMS

Confirm treatment‑resistant OCD prior to initiating deep TMS by documenting: diagnosis per DSM, age ≥18 years, failure of two or more adequate psychopharmacologic trials (≥8 weeks at therapeutic dose or documented intolerance), an adequate trial of evidence-based psychotherapy without significant improvement, and baseline and end-of-course Y‑BOCS scores.

Documentation Required

Migraine with aura — device prescription and training

For migraine with aura, include documentation that the device is prescribed and that the patient received device training when applicable. Note that TMS for migraine is considered not medically necessary per policy; submission may be denied unless covered under a specific benefit.

Documentation Required

Device FDA clearance relevance

Document use of a U.S. FDA‑cleared device for the indication being treated. Indicate device make/model and FDA clearance status in the record submitted with PA/claims; use of non‑FDA cleared devices for the indication may lead to denial.

Documentation Required

Evidence limitations to support coverage

When submitting prior authorization or claims, include rationale and objective measures because evidence is limited for some indications. The policy lists limitations of evidence for indications beyond MDD and OCD; include citations or clinical rationale when coverage is requested for less‑established uses.

Documentation Required

Policy revision awareness

Be aware of policy revisions and effective dates. Ensure documentation and coding reflect the policy effective date (2026-03-15) and current criteria; include dates of service and reference the policy number (EN0383) on inquiries when appropriate.

Satisfactory trials of first-line treatments without adequate response, usually defined by Y-BOCS score reduction >= 25% from baseline.

sTMSSingle-pulse transcranial magnetic stimulation (device modality used in some migraine indications; patient self-administered per FDA labeling)

TBSTheta Burst Stimulation: patterned bursts delivered as intermittent (iTBS) or continuous (cTBS), typically ~600 pulses per session to mimic theta rhythms.

SAINT/SNTStanford Accelerated Intelligent Neuromodulation Therapy / Stanford Neuromodulation Therapy — accelerated iTBS protocol (50 sessions of 1800 pulses/session as 10 daily sessions over five days with 50‑minute intersession intervals).

cTBS / iTBSContinuous (cTBS) or intermittent (iTBS) theta-burst protocols — high-frequency bursts in short sessions (e.g., 600 pulses in ~40 seconds for cTBS; iTBS sessions ~190 seconds).

nTMSNavigated transcranial magnetic stimulation — noninvasive brain mapping with navigation to map primary motor cortex for preoperative planning (e.g., Nexstim eXimia 510(k)).

3/15/2024annual_review

Annual Review 3/15/2024: No clinical policy statement changes. (Non-material)