CurrentColorado Rocky Mountain Health PlansPolicy CS124OH.F

Transcranial Magnetic Stimulation Oh Cs

Defines coverage stance for transcranial magnetic stimulation (TMS) used to treat non-behavioral (physical/neurological) conditions in the state of Ohio, lists unproven/not medically necessary indications, describes applicable procedure codes, and provides background evidence summaries. Part 1 of 3 — includes policy header, application, coverage rationale, applicable codes, and clinical evidence summaries for Alzheimer disease, epilepsy, headaches, and Parkinson disease.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTranscranial Magnetic Stimulation Oh Cs

Policy CodePolicy CS124OH.F

Change TypeRevised (title change; supporting sections updated)

Effective DateApr 1, 2026

Next Review Date

Key ActionRequests for services stated as unproven or with coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

SourceLink

POLICY UPDATE CHANGES

04/01/2026, Summary of Changes = Title Change. Previously titled 'Transcranial Magnetic Stimulation (for Ohio Only)'.

9Explicitly listed non-behavioral conditions

8Procedure codes referenced

limitedHigh-quality RCT Evidence

heterogeneous

Coverage Summary

This policy (Policy Number CS124OH.F, effective 2026-04-01) defines the coverage stance for transcranial magnetic stimulation (TMS) used to treat non-behavioral (physical/neurological) conditions in the state of Ohio only. The policy lists specific indications considered unproven or not medically necessary and provides applicable procedure codes and clinical evidence summaries. Coverage stance is mixed. This document is Part 1 of 3 and includes the policy header, application, coverage rationale, applicable codes, and clinical evidence summaries for Alzheimer disease, epilepsy, headaches, and Parkinson disease.

Key facts

Effective dateApril 1, 2026

Policy numberCS124OH.F

Coverage stanceMixed — TMS is considered unproven/not medically necessary for listed non‑behavioral conditions; some investigational uses and nTMS applications under study

Explicitly listed non‑behavioral conditions (count)9

Procedure codes referenced (count)8

Medical Necessity / Unproven Indications

Not Medically Necessary / Unproven Indications

The following are unproven and not medically necessary due to insufficient evidence of efficacy:

ALL of the following

Transcranial magnetic stimulation for treating all medical (i.e., non-behavioral) conditions including but not limited to: Alzheimer disease, Chronic neuropathic pain, Dystonia, Epilepsy, Headaches, Parkinson disease, Stroke, Tinnitus, Traumatic brain injury
Navigated transcranial magnetic stimulation for treatment planning or for diagnosing motor neuron diseases or neurological disorders
Theta-burst stimulation, including accelerated and/or magnetic resonance imaging-guided protocols

Clinical Evidence Conclusions

Evidence synthesis statements from the policy section:

Relevant Procedure and Product Codes

Relevant Procedure Codes (listed for reference)CPT

0858T	Externally applied transcranial magnetic stimulation with concomitant measurement of evoked cortical potentials with automated report.
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.
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.

FDA product codes referenced for informational purposesmixed

GWF	FDA product code referenced
HAW	FDA product code referenced
IKN	FDA product code referenced
OBP	FDA product code referenced
OCI	FDA product code referenced
OKP	FDA product code referenced

Applicable procedure and diagnosis codes are listed for reference only and do not by themselves determine coverage. Benefit coverage and coverage determinations depend on medical necessity and applicable federal, state (Ohio Administrative Code), or contractual requirements; inclusion of a code in this policy does not guarantee reimbursement.

Provider Actions & Documentation

Documentation Required

State Applicability and Medical Necessity Evaluation

Requests for services stated as unproven or with coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. Emphasize applicability of Ohio Administrative Code 5160-1-01 to evaluation of requests for these services.

Documentation Required

Evidence limitations and need for larger trials

Providers should note that evidence across indications is heterogeneous, often limited by small sample sizes, variable stimulation parameters, and inconsistent protocols; larger, well-designed randomized controlled trials are generally needed before routine adoption.

Background & Evidence Summaries

Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation modality that includes single-pulse TMS and repetitive TMS (rTMS); rTMS is being investigated as a treatment for several cortical-origin conditions such as pain, dystonia, epilepsy, headaches, Parkinson disease, stroke, and tinnitus. Navigated TMS (nTMS) is being studied as a diagnostic and treatment-planning tool for mapping functional cortical areas. Theta-burst stimulation (TBS), including accelerated and MRI-guided/intermittent protocols, is a newer noninvasive form of rTMS under investigation; current evidence for accelerated or MRI-guided theta-burst approaches is insufficient to conclude clinical benefit.

Definitions

HF-rTMS: High-frequency repetitive transcranial magnetic stimulation (frequency typically >1 Hz): High-frequency protocols (often >1 Hz) frequently target regions such as the DLPFC or M1 and are commonly used in clinical trials.

LF-rTMS: Low-frequency repetitive transcranial magnetic stimulation (typically 1 Hz): Low-frequency protocols (around 1 Hz) are used in some therapeutic approaches and research settings.

nTMS: Navigated transcranial magnetic stimulation used for preoperative cortical mapping: nTMS integrates anatomical imaging to stimulate precise cortical locations for motor and language mapping and treatment planning.

DLPFC: Dorsolateral prefrontal cortex: a common stimulation target in rTMS studies for cognitive and pain-related outcomes.

M1: Primary motor cortex: a frequent stimulation target for pain and motor rehabilitation studies.

Revision History

04/01/2026revisedLatest

04/01/2026, Summary of Changes = Title Change. Previously titled 'Transcranial Magnetic Stimulation (for Ohio Only)'.