CurrentKaiser PermanentePolicy N/A

Transcranial Magnetic Stimulation (TMS) for Treatment-Resistant Depression

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Clinical review criteria for use of repetitive and deep transcranial magnetic stimulation (rTMS/dTMS) for major depressive disorder and related indications, governing coverage determinations for Kaiser Foundation Health Plan of Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicyTranscranial Magnetic Stimulation (TMS) for Treatment-Resistant Depression

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Last ReviewMar 12, 2024

Next Review DateDec 2, 2025

Key ActionObtain prior authorization and submit supporting clinical documentation using CPT codes 90792 and 90867-90869 for TMS evaluations and treatments when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentKaiser PermanentePolicy N/A

Transcranial Magnetic Stimulation (TMS) for Treatment-Resistant Depression

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Policy Summary

PayerKaiser Permanente

PolicyTranscranial Magnetic Stimulation (TMS) for Treatment-Resistant Depression

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Last ReviewMar 12, 2024

Next Review DateDec 2, 2025

Key ActionObtain prior authorization and submit supporting clinical documentation using CPT codes 90792 and 90867-90869 for TMS evaluations and treatments when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90792, 90867-90869CPT codes specified

5/wk × 4–5 wksTypical acute schedule

NNT=6Short-term NNT

low–moderateAdolescent evidence certainty

510(k) clearedDevices with FDA clearance

MTAC Oct 2025MTAC review noted

Coverage Determinations

General coverage stance for rTMS/dTMS

Covered when applicable clinical criteria are met per the referenced MCG guideline and Kaiser MTAC determinations.

Evidence summary: There is short-term evidence that rTMS/dTMS may be superior to sham for depression, but evidence for long‑term efficacy and comparative superiority to established therapies is insufficient; individual coverage requires meeting policy-specific criteria and reviewer discretion.

Supported by MTAC reviews and meta-analyses (short-term NNT ~6).

Medical Necessity (general referral to main criteria)

Considered medically necessary when criteria in the applicable policy statements listed above are met.

Medical necessity statement: TMS (including rTMS, dTMS, iTBS) is considered medically necessary when the clinical criteria in the main policy and the referenced MCG guideline are met; evaluations for the explicit purpose of TMS will be reviewed against TMS-specific clinical criteria.

Providers must submit appropriate documentation and CPT codes (e.g., 90792, 90867-90869) for review.

Evidence and certainty for adolescents

Evidence summary for adolescent depression

Evidence certainty: Randomized controlled trials in adolescents have methodological weaknesses and inconsistent findings; the certainty of evidence for safety and effectiveness is downgraded to low or moderate.

This downgraded certainty informs conservative coverage decisions for adolescent TMS use.

Absolute contraindications include the presence of metallic or ferromagnetic objects in the head or eye, cochlear implants, implanted pacemakers, or other implants. Relative contraindications documented in the evidence review include history of epilepsy, prior skull trauma or cerebral injury, severe or recent heart disease, pregnancy, severe or frequent migraine, hearing loss, substance abuse, and other systemic illnesses; these should be considered when assessing candidacy for TMS/dTMS.

Migraine headache was explicitly removed as an indication in the policy update (10/10/2017). The policy history also notes that indication-specific behavioral health exclusions and other targeted exclusions have been added in prior revisions; see the main policy sections for the full list of indication-specific exclusions and their effective dates.

The policy states that rTMS/dTMS may be covered when applicable clinical criteria are met per the referenced MCG guideline and MTAC determinations. However, MTAC reviews have concluded there is insufficient evidence to determine long-term safety and efficacy and insufficient evidence to support superiority of rTMS over antidepressants; therefore individual coverage decisions require documentation that members meet the policy-specific clinical criteria and reviewer discretion per the referenced MCG criteria.

Policy history documents that denial language for deep TMS (dTMS) was added in 2018, reflecting MTAC review and specifying there are situations under which dTMS use may be denied. Providers should consult the policy denial language and clinical criteria when submitting requests for dTMS.

Procedure and Billing Codes

Considered Medically Necessary CPT CodesCPTCovered

90792	Psychiatric diagnostic evaluation with medical services.
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.

Covered CPT CodesCPTCovered

90792	Psychiatric diagnostic evaluation with medical services.
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.

dTMS pulses per session

Approximate pulses per dTMS sessionApproximately 1700–2000 magnetic pulses delivered over 15–20 minutes (series of 2‑second stimulations at 18–20 Hz with 20‑second pauses).

Stimulations per sessionOne treatment session equals ~40–55 discrete 2‑second stimulations (bursts).

Session frequency (acute course)Administered 5 days per week for 4–5 weeks during the acute phase.

TMS treatment session codes (brief definitions)

CPT 90867Initial therapeutic rTMS including cortical mapping, motor threshold determination, delivery and management.

CPT 90868Subsequent therapeutic rTMS delivery and management, per session.

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Authorization Required

Prior authorization required for TMS services — TMS evaluations and therapeutic sessions are subject to prior authorization and will be reviewed against TMS-specific clinical criteria. For behavioral health (treatment‑resistant depression) the criteria used = MCG B‑KP‑801‑T (effective 08/01/2024). For other diagnoses, cases require Medical Director review. Providers may request the specific MCG criteria used for an individual review by contacting Kaiser Permanente Clinical Review staff at 1‑800‑289‑1363 or via the provider portal (MCG Guideline Index).

Prior authorization required for initial and subsequent TMS treatment sessions and related evaluations
Behavioral Health (treatment‑resistant depression): MCG B‑KP‑801‑T (08/01/2024)
Other diagnoses: Medical Director review may be required

Documentation Required

Documentation and Coding

Documentation and coding — When a psychiatric diagnostic evaluation is performed explicitly for TMS treatment, document that purpose and submit the evaluation with the authorization request. Use CPT 90792 for psychiatric diagnostic evaluation with medical services when performed for the explicit purpose of TMS (include documentation of history, mental status, prior treatments, and rationale for TMS). Submit relevant clinical records showing prior antidepressant trials, response/tolerance, and any augmentation/switch strategies tried.

Care Setting and Level Criteria

Modalities: rTMS, dTMS, iTBS

rTMS / dTMS

Device indication: Devices such as NeuroStar (rTMS) and Brainsway (dTMS) have FDA 510(k) clearance for adult MDD patients who have failed one prior adequate antidepressant at an adequate dose and duration; device‑specific parameters and contraindications must be followed.failed ≥1 adequate antidepressant trial

dTMS session parameters: ~1700–2000 pulses per session; acute dTMS typically 5 days/week for 4–5 weeks.

TMS (rTMS, dTMS, iTBS)

Modalities referenced: Includes rTMS, deep TMS (dTMS), and intermittent theta‑burst stimulation (iTBS/accelerated iTBS); evidence and coverage vary by modality and indication and are governed by the main policy and referenced MCG criteria.

Policy history documents adoption of MCG hybrid criteria, amendments for continuation/extension therapy, and modality‑specific decisions (e.g., dTMS coverage history).

Definitions and Background

Repetitive Transcranial Magnetic Stimulation (rTMS)

DefinitionRepetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique that uses repetitive magnetic pulses, commonly targeting the left dorsolateral prefrontal cortex, to treat major depressive disorder.

Typical indicationsConsidered for adults with major depressive disorder who have failed at least one adequate antidepressant trial (see policy criteria).

Adverse effects / contraindicationsCommon side effects include scalp discomfort and headache; absolute contraindication: metallic or ferromagnetic implants in the head/eye, cochlear implants, implanted pacemakers, or other implants.

Deep Transcranial Magnetic Stimulation (dTMS) and H‑coil technology

DefinitionDeep transcranial magnetic stimulation (dTMS) uses H‑coil technology (Hesel‑coil) placed in a hood to stimulate deeper brain regions (penetration ~3–6 cm) compared with conventional rTMS.

Treatment Course and Visit Limits

dTMS sessions (acute treatment)

Typical acute course (dTMS)Five sessions per week during the acute phase (administered 5 days/week for 4–5 weeks).

Duration of acute courseAcute phase typically spans 4–5 weeks of daily weekday treatments.

Follow‑up/maintenanceUsually followed by a maintenance phase with less frequent treatments for up to 12 weeks as clinically indicated.

Continuation and extension therapy (policy note)

Policy note on continuation/extension therapyContinuation and extension therapy criteria were amended in 2020 and exist in the main policy document, but specific visit limits are not present in this extract.

Implication for reviewers/providersReviewers should refer to the full policy for continued and extension therapy authorization criteria and any visit‑limit guidance.

Policy History and Revisions

2015-09-08policy_reference_update

Revised LCD L34886 and L35008 non-covered services referenced in policy history.

2017-10-03policy_adoption

Medical Policy Committee (MPC) approved adoption of MCG hybrid criteria for rTMS.

2017-10-10indication_change

Migraine headaches were removed as an indication for TMS.

Policy Summary

PayerKaiser Permanente

PolicyTranscranial Magnetic Stimulation (TMS) for Treatment-Resistant Depression

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Last ReviewMar 12, 2024

Next Review DateDec 2, 2025

Key ActionObtain prior authorization and submit supporting clinical documentation using CPT codes 90792 and 90867-90869 for TMS evaluations and treatments when criteria are met.

SourceLink

On This Page

CPT 90869Subsequent motor threshold re‑determination with delivery and management.

Use CPT 90792 when the psychiatric diagnostic evaluation is performed for explicit purpose of TMS
Therapeutic TMS CPT codes: 90867 (initial, including motor threshold determination and delivery/management); 90868 (subsequent delivery and management, per session); 90869 (subsequent motor threshold re‑determination with delivery/management)
Include documentation of prior antidepressant trials (agent, dose, duration, reason for discontinuation), psychotherapy trials, and objective clinical measures

Step Therapy

Step / Continuation Therapy Reference

Step/continuation therapy reference — TMS is considered after failure of adequate antidepressant therapy per the applicable clinical criteria (e.g., failure of at least one adequate antidepressant trial as specified in the MCG hybrid criteria). Continued or extension TMS therapy requirements follow the adopted MCG hybrid criteria and any amended continuation/extension therapy rules approved by the Medical Policy Committee; refer to the applicable clinical criteria for specifics on number of sessions, response thresholds, and maintenance/extension indications.

TMS sequencing: considered after inadequate response to prior antidepressant treatment and/or augmentation strategies as defined in the clinical criteria
Continuation/extension therapy follows MCG hybrid criteria adopted 10/10/2017 and amended criteria approved by MPC (most recently revised 03/12/2024 effective 08/01/2024)
Providers must document prior treatment history and clinical response to support continuation or extension requests

Session parametersdTMS sessions deliver series of 2‑second stimulations at 18–20 Hz with 20‑second pauses; total of ~1700–2000 pulses over 15–20 minutes.

Regulatory statusBrainsway Deep TMS system received FDA 510(k) clearance for adults with MDD who failed prior antidepressant treatment (device includes H1 coil, neurostimulator, cooling and positioning systems).

TMS treatment session codes (CPT summaries)

90867Initial therapeutic rTMS: includes cortical mapping and motor threshold determination, delivery and management.

90868Subsequent therapeutic rTMS: delivery and management, per session.

90869Subsequent therapeutic rTMS with motor threshold re‑determination: delivery and management.

Major depressive disorder is a common condition typically managed initially with antidepressant medication and psychotherapy; many patients respond to first-line pharmacotherapy but a substantial minority have inadequate response. Noninvasive brain stimulation options such as rTMS and dTMS are considered in patients who have not achieved satisfactory response to prior adequate antidepressant trials. dTMS uses an H-coil to target deeper brain regions and acute courses are commonly delivered 5 days per week for 4–5 weeks; reported adverse effects are generally mild (scalp discomfort, headache, transient hearing changes) though rare seizures have been reported.

History referencePolicy history documents the 03/03/2020 MPC amendment adding continued and extension therapy language to the hybrid TMS criteria (B‑KP‑801‑T).

2018-09-20denial_language_added

MTAC review and denial language for deep TMS (dTMS) were added to the policy.

2018-11-06coverage_approval

MPC approved coverage for deep transcranial magnetic stimulation (dTMS).

2019-03-05indication_extension

MPC approved adding the indication to include patients 18 years and older.

2020-03-03criteria_amendment

MPC approved amended hybrid TMS criteria (B-KP-801-T) to include behavioral health exclusions, continued therapy, and extension therapy criteria.

2023-11-20mtac_review_added

March 2023 MTAT review for repetitive TMS for bipolar depression was added to policy history.

2024-03-12criteria_revision_approval

MPC approved revised clinical criteria for TMS effective August 1, 2024, with 60-day notice.

2024-05-22coding_update

Added CPT code 90792 and clarified that evaluations performed for the explicit purpose of TMS will be reviewed against clinical TMS criteria.

2025-12-02mtac_review_addedLatest

Added the October 2025 MTAC review to the policy history.