CurrentColorado Rocky Mountain Health PlansPolicy CS124.P

Transcranial Magnetic Stimulation for Treating Physical Health Conditions

This policy governs use and coverage stance for transcranial magnetic stimulation (TMS) when used to treat non-behavioral (physical/neurological) health conditions for Colorado Rocky Mountain Health Plans members; it lists conditions considered unproven and provides supporting evidence summaries. It excludes specified states where separate state-specific policies apply.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTranscranial Magnetic Stimulation for Treating Physical Health Conditions

Policy CodePolicy CS124.P

Change TypeAdministrative and archival updates

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and provide indication‑specific rationale, prior conservative therapies tried, and planned stimulation parameters when requesting TMS services.

SourceLink

POLICY UPDATE CHANGES

Updated reference link to reflect the current title for state-specific policy version for Idaho and other states.

Removed content/language pertaining to the state of Louisiana.

Policy title changed from 'Transcranial Magnetic Stimulation' and supporting sections updated (Description of Services, Clinical Evidence, References).

listUnproven conditions

8 codesProcedure codes listed

8 studiesEpilepsy trials

OR 0.54nTMS benefit (motor deficits)

Coverage Criteria and Evidence Summary

General policy coverage stance

Covered when ALL of the following are met:

Primary coverage stance: Transcranial magnetic stimulation for treating all medical (non-behavioral) conditions is considered unproven and not medically necessary due to insufficient evidence of efficacy.

See condition-specific evidence summaries and exclusions for examples of indications considered unproven or investigational.

Alzheimer disease — evidence summary

Summary of evidence and guideline stance

Alzheimer disease evidence: Meta-analysis of five RCTs (148 individuals) reported HF-rTMS improved cognition on the Assessment Scale–Cognitive Subscale and global impression but not MMSE; sample sizes were small and underpowered to detect definitive effects.

NICE recommends that noninvasive brain stimulation (including TMS) should not be offered for mild to moderate Alzheimer disease except in randomized controlled trials.

Epilepsy — evidence summary

Cochrane and systematic review findings

Epilepsy evidence: Multiple randomized trials (total ~230–241 individuals) showed inconsistent results: two trials reported large reductions in seizure frequency while most trials showed no significant difference; some studies reported reductions in epileptiform discharges; overall certainty judged low to very low.

Adverse events were uncommon but increased seizure frequency occurred in a small number of individuals; heterogeneity in techniques and outcomes precludes definitive conclusions.

Headaches / Migraine — evidence summary

Systematic reviews, meta-analyses and guideline positions

Migraine evidence: Multiple meta-analyses and network meta-analyses (including up to 19 RCTs, n≈1,493 in pooled analyses) report that HF-rTMS can reduce monthly migraine days and headache frequency in some trials, but heterogeneity of stimulation parameters, small sample sizes, and inconsistent outcomes limit confidence in effect size and durability.

NICE and European guidance advise use only with special arrangements or within research because evidence quantity and quality are limited and long-term safety is uncertain.

Parkinson disease — evidence summary

rTMS for motor and nonmotor symptoms in PD

Parkinson evidence: Multiple RCTs and meta-analyses (ranges: 14–23 studies; pooled subjects up to several hundred) report short-term motor function improvements with HF-rTMS and some benefits for gait and freezing of gait; cognitive findings are mixed and protocols are heterogeneous.

Authors recommend larger, high-quality trials to determine optimal stimulation parameters and long-term benefit.

Pain — evidence summary

rTMS for neuropathic and chronic pain

Pain evidence: RCTs and meta-analyses indicate HF-rTMS over motor cortex or left DLPFC may produce short-term analgesia in neuropathic pain (including SCI and DPN) and reductions in pain-related disability, but studies are small, heterogeneous, and follow-up is short; overall certainty is low and clinical significance is often uncertain.

Some meta-analyses report statistically significant standardized mean differences for neuropathic pain, but effects are frequently transient and may not meet minimal clinically important difference thresholds.

Coverage evidence by clinical indication

Evidence summary and coverage implications for rTMS by indication

Neuropathic pain (M1 stimulation): Multiple RCTs and systematic reviews report statistically significant but generally transient pain reductions with high-frequency rTMS targeting M1; certainty ranges from very low to low and effects often do not meet minimal clinically important differences; long-term benefit is unproven.

Evidence supports possible short-term use or use as a predictor for motor cortex stimulation response, but routine coverage is not supported without stronger evidence.

Tinnitus: Meta-analyses of randomized sham-controlled trials report rTMS is superior to sham for Tinnitus Handicap Inventory scores at short- and longer-term follow-up in pooled analyses, though guideline groups (AAO-HNS) recommend against routine use for persistent bothersome tinnitus.

Systematic reviews (Yin et al., Liang et al.) found improvements in THI scores, but specialty guidance advises against routine recommendation.

Stroke motor recovery and spasticity: Systematic reviews and network meta-analyses report mixed, often short-term effects of LF- or HF-rTMS on specific motor outcomes (e.g., Fugl–Meyer, balance, mobility); heterogeneity and inconsistent protocols limit definitive conclusions and evidence for spasticity improvement is inconclusive.

nTMS for surgical planning

Coverage stance is evidence-dependent by indication; nTMS for preoperative motor/language mapping shows supportive evidence but high-level RCTs are limited.

nTMS for preoperative motor mapping: nTMS mapping is associated with reduced risk of new permanent postoperative motor deficits and increased gross total resection rates in observational comparative studies and meta-analyses, supporting its clinical usefulness for planning resection of motor-eloquent brain tumors.evidence from observational studies and meta-analyses

Well-designed multicenter RCTs are still needed; prior authorization and documentation of intended surgical plan are reasonable due to limited RCT data.

Therapeutic rTMS/TBS

Therapeutic TMS and TBS coverage is indication-specific and limited by available evidence.

rTMS/TBS for cognitive deficits or other off-label neurologic conditions: Evidence for therapeutic uses of rTMS and theta-burst stimulation in cognitive disorders and other off-label neurologic indications is mixed or inconclusive (e.g., no cognitive benefit in a small chronic diffuse axonal injury RCT; preliminary small trials for MRI-guided or accelerated TBS), and therefore such uses are considered investigational or not established without strong supporting documentation.small, heterogeneous RCTs and pilot studies

Accelerated or MRI-guided TBS protocols lack sufficient evidence of clinical benefit and should be considered investigational pending further trials.

The policy identifies that transcranial magnetic stimulation (TMS) for treating all medical (non‑behavioral) conditions is unproven and not medically necessary because of insufficient evidence of efficacy. Explicit examples listed include: Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches, Parkinson disease, stroke, tinnitus, and traumatic brain injury.

For Alzheimer disease, a meta-analysis of five randomized trials (148 participants) found some improvement on the Assessment Scale‑Cognitive Subscale and global impression with high‑frequency rTMS but not on MMSE, and reviewers noted trials were small and underpowered; accordingly, NICE advises that noninvasive brain stimulation (including TMS) should not be offered for mild to moderate Alzheimer disease except as part of a randomized controlled trial.

For migraine, NICE (2014) concluded evidence for TMS in treating and preventing migraine is limited in quantity and quality and that long‑term safety is uncertain; therefore, TMS for migraine should be used only with special arrangements for clinical governance, consent, audit, or within research settings.

The American Academy of Otolaryngology–Head and Neck Surgery guideline on tinnitus (Tunkel et al., 2014) explicitly states that clinicians should not recommend TMS for the treatment of patients with persistent, bothersome tinnitus.

Reflecting the AAO‑HNS guideline, this policy states that TMS is not recommended for persistent, bothersome tinnitus and that routine use for tinnitus is not supported by available guideline recommendations and evidence.

Administrative edits have removed state‑specific language referencing Louisiana from the template; this is an administrative cleanup and does not alter clinical coverage positions.

Summary policy position: TMS for non‑behavioral (medical/neurologic) conditions is considered unproven and not medically necessary because current evidence across multiple physical health indications is insufficient to establish consistent, clinically meaningful benefit.

For many chronic pain indications, systematic reviews and meta‑analyses report heterogeneous small trials with at best transient reductions in pain intensity; pooled effects are generally small and often fall below commonly accepted minimal clinically important difference thresholds, leading to a conclusion of insufficient or low‑quality evidence to support routine use.

Protocols described as accelerated or MRI‑guided theta‑burst stimulation (TBS) lack adequate clinical evidence demonstrating benefit; because studies demonstrating safety and clinical efficacy are lacking, these approaches are considered investigational/not established.

Modalities and Device Types

Theta-burst stimulation — top-level node

Theta-burst description: Theta-burst stimulation is a patterned form of rTMS delivering short bursts of pulses at higher frequency with specific interburst timing; accelerated protocols shorten overall treatment time and MRI-guided/functional connectivity–guided approaches are under investigation.

Clinical use and safety of accelerated or MRI-guided TBS are not established.

rTMS — top-level node

rTMS use across conditions: rTMS has been studied for multiple neurophysiologic conditions and may yield short-term benefits in migraine prophylaxis, certain neuropathic pain conditions, and motor symptoms in Parkinson disease, but evidence quality varies and protocols are heterogeneous.

Long-term efficacy and standardized protocols are not established; indication-specific evidence summaries should guide coverage decisions.

CES — top-level node

Provider Requirements, Prior Authorization, and Documentation

Note

Procedure codes referenced for authorization (reference only — inclusion does not imply coverage)

Procedure codes listed in this policy are for reference only and do not guarantee coverage or authorization. Inclusion of a code does not imply that the service is a covered clinical benefit under member-specific plan documents.

See Applicable CPT/HCPCS Codes block for CPT/HCPCS codes. Verify plan-specific prior authorization and benefit rules.

Prior Authorization

Migraine — restricted use / prior authorization suggested (NICE special arrangements/research)

For migraine (including treatment and prevention), NICE recommends use only with special arrangements for clinical governance, consent, audit, or research; prior authorization or restricted-use arrangements are suggested.

Procedure and Billing Codes

Procedure codes included for referenceCPT

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.

Definitions and Key Terms

Theta-burst stimulation definition

DefinitionTheta-burst stimulation (TBS) is a patterned form of rTMS in which short bursts (typically 3–5 pulses) are delivered at a higher intraburst frequency with specific interburst timing to produce an overall lower net frequency.

Common protocolsIncludes intermittent TBS (iTBS, excitatory) and continuous TBS (cTBS, inhibitory).

Accelerated approachesAccelerated TBS protocols shorten overall treatment time by delivering multiple sessions per day; these are under investigation.

Investigational variationsEmerging methods include MRI-guided, functional connectivity–guided TBS for personalized targeting; evidence is preliminary.

Navigated TMS definition

Definition

Background and Clinical Context

Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that can be used diagnostically (single‑pulse motor mapping) or therapeutically (repetitive TMS, theta‑burst protocols). While some small randomized trials and meta‑analyses report short‑term signals of benefit for selected neurologic conditions (for example, limited cognitive measures in Alzheimer disease trials, transient analgesia in neuropathic pain trials, and trial‑level effects in migraine), the overall evidence base is limited by small sample sizes, heterogeneity of stimulation targets and parameters, and short follow‑up. As a result, for non‑behavioral medical conditions the policy considers routine therapeutic use of TMS unproven and not medically necessary, with specific indications (e.g., accelerated/MRI‑guided TBS, tinnitus) or applications (navigated preoperative mapping) evaluated separately based on available evidence and guideline recommendations.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTranscranial Magnetic Stimulation for Treating Physical Health Conditions

Policy CodePolicy CS124.P

Change TypeAdministrative and archival updates

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and provide indication‑specific rationale, prior conservative therapies tried, and planned stimulation parameters when requesting TMS services.

SourceLink

On This Page

Findings are preliminary and require larger, standardized trials.

Other indications (poststroke neurogenic bladder, TBI cognitive impairment): Small randomized trials report promising signals for some indications (e.g., poststroke neurogenic bladder) and no benefit in small TBI cognitive trials; these are preliminary and insufficient to support routine coverage.

Single-center or small RCTs require replication in larger multicenter studies.

CES for anxiety after SCI: Cranial electrotherapy stimulation (CES) showed a significant reduction in anxiety immediately after treatment in subgroup analyses of NIBS trials for post-spinal-cord-injury neuropathic pain, whereas rTMS and tDCS did not consistently show this effect.

Evidence is limited and does not support routine use for neuropathic pain; CES signal for anxiety requires further validation.

rTMS — top-level node (alternate)

rTMS for neuropathic pain and chronic pain: High-frequency rTMS targeting M1 or DLPFC may produce short-term analgesia in neuropathic and chronic pain conditions, but pooled effects are small, heterogeneous, and often do not meet minimal clinically important differences; evidence quality ranges from very low to low.

Multiple-session rTMS may sustain longer effect than single sessions, but long-term clinical benefit is unproven.

Theta-burst stimulation (TBS) — top-level node

TBS research status: Theta-burst stimulation (iTBS and cTBS), including accelerated and MRI-guided connectivity approaches, is an active area of research with preliminary positive signals in small trials for memory and OCD, but current evidence is insufficient to establish routine clinical benefit.small RCTs and pilot studies

Accelerated and MRI-guided protocols currently lack adequate evidence and are considered investigational.

rTMS / Noninvasive brain stimulation — top-level node

Referenced modalities: Repetitive transcranial magnetic stimulation and other noninvasive brain stimulation modalities are discussed across the literature for various neuropsychiatric and neurological indications; specific modality choice and parameters materially affect outcomes and should be documented in requests.

See modality- and indication-specific evidence summaries for details.

NICE (2014): TMS for migraine should only be used with special arrangements for governance, consent, audit, or research

Prior authorization is suggested to ensure governance and documentation of research or approved special arrangements

Documentation Required

Require indication-specific justification and treatment plan for authorization requests

Requests for authorization must include indication‑specific justification and a treatment plan outlining prior therapies tried, treatment target, stimulation protocol, and planned number of sessions. Insufficient or absent documentation may result in delay or denial.

Provide indication and clinical rationale
Specify target area (e.g., left dorsolateral prefrontal cortex), coil type, frequency/intensity, and protocol (e.g., HF‑rTMS, iTBS)
Provide number of planned sessions and schedule
List dates and outcomes of prior conservative/ guideline‑directed therapies

Prior Authorization

Prior authorization for navigated TMS for preoperative motor/language mapping

Navigated TMS used for preoperative motor or language mapping requires prior authorization with submission of the clinical indication, relevant imaging, and a mapping report. Authorization may be granted when nTMS is requested to inform operative approach for motor‑ or language‑eloquent brain tumors.

Indication: preoperative motor or language mapping for brain tumor resection
Submit corresponding MRI (structural and resting‑state if used) and the neuronavigation/mapping report
Provide planned use of mapping results in surgical approach and expected impact on extent of resection or functional preservation

Note

Verify plan-specific prior authorization — policy informational only

When plan language or benefit documents conflict with this policy, the member-specific federal, state, or contractual requirements govern. Verify benefit coverage, medical necessity definitions, and any required step therapy or investigational exclusions before approving services.

This policy is informational; in event of conflict, federal/state/contractual requirements govern
Check member benefit booklet and state/federal mandates before making coverage determinations

Denial Risk

Denial risk for listed physical health conditions — TMS considered unproven and not medically necessary

Denial risk: Several physical health conditions (Alzheimer disease, epilepsy, chronic neuropathic pain, stroke, tinnitus, headache/migraine, dystonia, Parkinson disease, traumatic brain injury) are considered unproven or have insufficient evidence for TMS; requests for these indications may be denied as not medically necessary.

Alzheimer disease: per NICE (2018) NIBS/TMS should not be offered for mild‑to‑moderate AD except in RCTs
Epilepsy: evidence inconsistent; seizure‑reduction efficacy low to very low certainty
Chronic neuropathic pain, stroke spasticity, tinnitus, migraine/headache: limited/heterogeneous evidence; may be considered unproven

Denial Risk

Alzheimer disease — research-only per NICE (do not offer except in RCTs)

Alzheimer disease: current evidence is limited, sample sizes are small, and NICE guidance recommends TMS be offered only within randomized controlled trials. Authorization for routine clinical use for AD is not supported; consider coverage only for approved research protocols.

Dong et al. (2018): small RCTs with some cognitive signal but insufficient evidence for routine use
NICE (2018): do not offer TMS for mild‑to‑moderate AD except in RCTs — treat as research only

Prior Authorization

Epilepsy — require trial of standard therapy before considering rTMS

Epilepsy: require documentation of a trial of standard antiepileptic therapy and clear reporting of seizure frequency and prior treatments. Due to heterogeneity and low‑certainty evidence for seizure reduction, requests must include detailed prior therapy history.

Document diagnosis of drug‑resistant epilepsy and anticonvulsant medication trials (names, doses, durations)
Provide baseline seizure frequency (diary) and objective EEG/epileptiform discharge data if available
List prior nonpharmacologic interventions (e.g., surgery, VNS, ketogenic diet) and responses
State rationale for rTMS and proposed stimulation parameters

Step Therapy

Step therapy / investigational status for accelerated/MRI-guided TBS — require justification

Step‑therapy and investigational note: accelerated and MRI‑guided theta‑burst stimulation (TBS), including high‑dose accelerated protocols and MRI‑guided targeting, currently lack sufficient evidence for safety and effectiveness. Authorization requires strong justification documenting why standard rTMS was inadequate and why accelerated/MRI‑guided TBS is clinically necessary.

Codes 0889T–0892T (accelerated MRI‑guided TBS) are considered investigational/experimental in absence of robust evidence — prior authorization may be denied without strong justification
Require documentation of failure/inadequate response to guideline‑directed rTMS or other standard therapies and rationale for accelerated/MRI‑guided approach

Documentation Required

Recommended documentation for rTMS requests (prior treatments, target, protocol, sessions)

Authorization requests for routine rTMS should include specific documentation: prior treatments and responses, precise target and laterality, stimulation protocol and parameters, session count and schedule, and objective measures of clinical status.

Clinical indication and severity measures (e.g., PHQ‑9 for depression, pain scores, seizure frequency)
Prior conservative or guideline‑directed therapies tried and response (medications, psychotherapy, physical therapy)
Target brain region (e.g., left DLPFC), coil type, frequency/intensity, train duration, intertrain interval, and total pulses per session
Total number of planned sessions, frequency (e.g., daily), and criteria for continuation or discontinuation
Outcome measures and timeline for reassessment

Documentation Required

Documentation for navigated TMS requests (indication, imaging, mapping report)

For navigated TMS (nTMS) authorization, submit imaging and mapping documentation: structural MRI (and resting‑state fMRI if used), neuronavigation files or target report, and a mapping report describing motor/language mapping results and their anticipated surgical impact.

Provide structural and functional imaging used for navigation (dates and protocols)
Include neuronavigation export files and the target report (motor threshold, coordinates, predicted eloquent cortex locations)
Attach mapping report and interpretation and describe how results will change surgical planning or reduce operative risk

Navigated TMS (navigated transcranial magnetic stimulation) uses neuronavigation to map and target cortical areas at precise anatomical locations for diagnostic mapping and treatment planning.

Primary usesStudied for preoperative mapping of motor and language areas to inform surgical planning.

Evidence noteData are limited by small studies and heterogeneous designs; larger trials are needed to define clinical impact on outcomes.

NIBS / rTMS definition

DefinitionNoninvasive brain stimulation (NIBS) encompasses techniques that modulate cortical activity without surgery, including repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and cranial electrotherapy stimulation (CES).

rTMS descriptionRepetitive transcranial magnetic stimulation delivers repeated magnetic pulses to induce changes in brain activity that can outlast stimulation periods and has been investigated for pain, headaches, Parkinson disease, stroke, tinnitus, epilepsy, and cognitive disorders.

Guideline perspectiveNICE classifies TMS under NIBS and recommends restricted or research-only use for certain indications (e.g., dementia, migraine) due to limited evidence quality/quantity.

HF-rTMS definition

DefinitionHigh-frequency rTMS (HF-rTMS) commonly refers to stimulation frequencies in the 5–20 Hz range, typically applied to cortical targets such as primary motor cortex (M1) or dorsolateral prefrontal cortex (DLPFC).

Clinical effectsHF-rTMS has been used in trials to produce short-term analgesia for neuropathic pain and to improve motor symptoms in Parkinson disease; effects are often transient and study protocols are heterogeneous.

Evidence certaintySystematic reviews note very-low to low certainty for many HF-rTMS indications and call for larger, rigorous trials to establish long-term benefit and standardized parameters.

NIBS definition (alternate)

DefinitionNoninvasive brain stimulation (NIBS) is an umbrella term for non-surgical neuromodulation methods—most commonly rTMS, tDCS, and CES—used to modulate cortical excitability for diagnostic or therapeutic purposes.

ScopeNIBS modalities have been studied across conditions including chronic pain, neuropathic pain after SCI, Alzheimer's disease, and psychiatric disorders; evidence quality varies by modality and indication.

LimitationsHeterogeneous protocols, small sample sizes, and short follow-ups limit conclusions about clinical effectiveness across NIBS techniques.

nTMS (navigated transcranial magnetic stimulation) definition

DefinitionnTMS (navigated transcranial magnetic stimulation) integrates neuronavigation with TMS to perform high-accuracy preoperative mapping of cortical motor and language areas for surgical planning.

Clinical applicationUsed to identify motor/language-eloquent cortex and to assist surgical strategy for brain tumor resection; comparative studies vs intraoperative direct cortical stimulation (DCS) have been reported.

Evidence limitationsAvailable studies are largely observational or small prospective/retrospective cohorts; standardized protocols and larger trials are needed to confirm impact on surgical outcomes.

Theta-burst stimulation (TBS) definition and protocol notes

DefinitionTheta-burst stimulation (TBS) is a patterned rTMS approach delivering short high-frequency bursts (e.g., 3 pulses/burst) with defined interburst intervals; it can be delivered as intermittent (iTBS) or continuous (cTBS).

Protocol notesiTBS is generally considered excitatory and cTBS inhibitory; accelerated and MRI-guided TBS protocols are under investigation but lack robust evidence for routine clinical benefit.

Research considerationsSmall RCTs and pilot studies report variable results (e.g., MCI memory improvement, inconclusive OCD findings); sample sizes and heterogeneity limit definitive conclusions and longer-term outcome data are lacking.

Noninvasive brain stimulation umbrella definition

DefinitionNoninvasive brain stimulation (NIBS) is an umbrella term for techniques that modulate brain activity without surgery, primarily including rTMS, theta-burst stimulation (TBS), transcranial direct current stimulation (tDCS), and cranial electrotherapy stimulation (CES).

Typical usesThese modalities are investigated for diagnostic mapping (single-pulse TMS/nTMS) and therapeutic indications such as pain, headaches/migraine, epilepsy, Parkinson disease, stroke rehabilitation, tinnitus, and cognitive disorders.

Evidence summaryAcross indications, evidence is heterogeneous and generally limited by small trials and variable protocols; guideline bodies (e.g., NICE) recommend restricted or research-only use for several indications due to insufficient high-quality evidence.