CurrentLouisiana Department of HealthPolicy 24-27

Transcranial Magnetic Stimulation (TMS)

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Louisiana Medicaid coverage and claims processing for TMS in adult members with major depressive disorder or persistent depressive disorder, subject to specified clinical criteria and hard-copy documentation.

Policy Summary

PayerLouisiana Department of Health

PolicyTranscranial Magnetic Stimulation (TMS)

Policy CodePolicy 24-27

Change TypeAdded coverage

Effective DateAugust 2, 2024

Next Review DateNot specified

Key ActionSubmit hard-copy supporting documentation with the claim.

SourceLink

POLICY UPDATE CHANGES

Louisiana Medicaid added coverage for TMS for major depression and persistent depressive disorder in accordance with FDA approval.

The Medicaid procedure file and reimbursement systems were updated to reflect the TMS coverage and rate change.

18+Minimum member age

4Required unsuccessful medication trials

2Agent classes represented

6 weeksMinimum adequate trial duration

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CurrentLouisiana Department of HealthPolicy 24-27

Transcranial Magnetic Stimulation (TMS)

Customize your policy alerts

Sign up for Louisiana Department of Health Policy 24-27 alerts

Get alerted when Policy 24-27 changes without checking for updates manually.

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Policy Summary

PayerLouisiana Department of Health

PolicyTranscranial Magnetic Stimulation (TMS)

Policy CodePolicy 24-27

Change TypeAdded coverage

Effective DateAugust 2, 2024

Next Review DateNot specified

Key ActionSubmit hard-copy supporting documentation with the claim.

SourceLink

POLICY UPDATE CHANGES

Louisiana Medicaid added coverage for TMS for major depression and persistent depressive disorder in accordance with FDA approval.

The Medicaid procedure file and reimbursement systems were updated to reflect the TMS coverage and rate change.

18+Minimum member age

4Required unsuccessful medication trials

2Agent classes represented

6 weeksMinimum adequate trial duration

30 daysMCO system update deadline

Hard copy requiredClaims documentation

TMS Coverage Criteria

Initial TMS Medical Necessity

TMS is medically necessary when ALL of the following criteria are met.

TMS medical necessity

Member and diagnosis: The member is 18 years of age or older and has a diagnosis of major depressive disorder or persistent depressive disorder using DSM-5 diagnostic terminology.Age >= 18
Psychotherapy failure: The member has failed a full course of evidence-based psychotherapy, such as cognitive behavioral therapy, for the current depressive episode.Full course for current episode
Psychopharmacologic failure or intolerance
- Failure of psychopharmacologic agents: There was no clinically significant response in the current depressive episode to four trials of agents from at least two different agent classes, and at least two trials were adequate courses of mono- or poly-drug therapy with antidepressants at standard therapeutic doses for at least six weeks.4 trials; >= 2 agent classes; >= 2 adequate trials of >= 6 weeks
- Unable to take antidepressants
  - Drug interactions with medically necessary medications.
  - Inability to tolerate psychopharmacologic agents, as evidenced by trials of four such agents with distinct side effects in the current episode.4 agents with distinct side effects
No contraindications to TMS are present.None present
See the section on contraindications.
ECT status: Electroconvulsive therapy has previously been attempted, is medically contraindicated, or has been offered and declined by the member.

Louisiana Medicaid covers Transcranial Magnetic Stimulation (TMS) in accordance with FDA approval for adults with major depressive disorder or persistent depressive disorder only. Coverage does not extend to other indications and requires satisfaction of the policy’s medical-necessity criteria, including the specified psychotherapy, medication-treatment or intolerance, contraindication, and ECT requirements.

Provider Documentation and Claim Requirements

Step Therapy

Prior Psychotherapy Required

Document that the member completed and failed a full course of evidence-based psychotherapy for the current depressive episode, such as cognitive behavioral therapy.

Required: Full-course failure must be documented for the current depressive episode.

Step Therapy

Prior Medication Treatment or Intolerance

Document unsuccessful or intolerant antidepressant treatment meeting one of the required pathways.

Unsuccessful treatment: No clinically significant response during the current episode to four trials from at least two different agent classes; at least two trials must be adequate courses of mono- or poly-drug antidepressant therapy at standard therapeutic doses for at least six weeks.
Intolerance or inability to take antidepressants: Document medically necessary medication interactions, or trials of four psychopharmacologic agents during the current episode that produced distinct side effects.

Treatment Overview

TMS is a noninvasive treatment that delivers a magnetic field through the skull, inducing electrical currents that affect neuronal function. It can be performed in an office setting without anesthesia and does not induce a convulsion.

Key Terms

Transcranial Magnetic Stimulation (TMS)

DefinitionA noninvasive method of delivering electrical stimulation to the brain by applying a magnetic field through the skull, inducing electric currents that affect neuronal function.

DSM-5 diagnostic terminology

Required standardThe diagnosis of major depressive disorder or persistent depressive disorder must use DSM-5 diagnostic terminology.

TMS Treatment Modality

TMS

TMS eligibility: The member is at least 18 years old; has major depressive disorder or persistent depressive disorder using DSM-5 diagnostic terminology; has failed a full course of evidence-based psychotherapy for the current depressive episode; meets one of the specified medication failure or intolerance pathways; has no contraindications to TMS; and has attempted, been medically unable to receive, or declined offered electroconvulsive therapy.All criteria required

Policy Summary

PayerLouisiana Department of Health

PolicyTranscranial Magnetic Stimulation (TMS)

Policy CodePolicy 24-27

Change TypeAdded coverage

Effective DateAugust 2, 2024

Next Review DateNot specified

Key ActionSubmit hard-copy supporting documentation with the claim.

SourceLink

On This Page

Prior Authorization

ECT Prerequisite or Exception

Document that electroconvulsive therapy (ECT) was previously attempted, is medically contraindicated, or was offered and declined by the member.

The record must clearly identify which ECT pathway applies: attempted, medically contraindicated, or offered and declined.

Documentation Required

Required Supporting Documentation

Submit the required hard-copy supporting documentation with the claim. The documentation must provide clinical evidence that the TMS medical-necessity criteria are satisfied.

Include hard-copy records supporting the member's diagnosis, age, prior psychotherapy failure, medication treatment failure or intolerance, absence of TMS contraindications, and applicable ECT pathway.
If hard-copy supporting documentation is present and meets the clinical criteria, the claim may continue normal processing.

Documentation Required

Clinical Medical-Necessity Record

The clinical medical-necessity record must support every required element for TMS coverage.

Member is 18 years of age or older.
Diagnosis is major depressive disorder or persistent depressive disorder using DSM-5 diagnostic terminology.
Full course of evidence-based psychotherapy failed for the current depressive episode.
Required psychopharmacologic-agent failure or inability to take antidepressants is documented, including agent classes, adequate-course duration, doses, or distinct side effects as applicable.
No TMS contraindications are present.
ECT was attempted, medically contraindicated, or offered and declined.

Denial Risk

Missing Hard-Copy Documentation

Claims will be denied when the required hard-copy documentation is not present.

Missing hard-copy supporting documentation: Claim denied.
Hard-copy documentation must accompany the claim and demonstrate the applicable clinical criteria.

Denial Risk

Clinical Criteria Not Met

TMS is covered only when all medical-necessity criteria are satisfied. Claims that do not meet the clinical requirements are not eligible for coverage and may be denied.

The member must be at least 18 years old and have major depressive disorder or persistent depressive disorder.
All required psychotherapy, medication, contraindication, and ECT criteria must be documented.
Hard-copy documentation must be present and support the clinical criteria for the claim to continue normal processing.

Denial Risk

Noncovered Indications

Louisiana Medicaid covers TMS in accordance with FDA approval for major depression and persistent depressive disorder only.

Indications outside major depressive disorder or persistent depressive disorder are noncovered under this policy.