Transcranial Magnetic Stimulation (TMS) for Major Depression
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Policy governing coverage and medical necessity criteria for transcranial magnetic stimulation (TMS) to treat major depressive disorder, including training requirements, eligible patient criteria, treatment protocols, exclusions, and coding guidance for providers and clinics seeking authorization.
Clarified language regarding ECT recommendations.
Add child and adolescent indication from the FDA.
Updated the summary of evidence.
Florida Blue requires age to start at 15 years old.
10 references removed.
3 references added.
Coverage and Medical Necessity Criteria
Initial Authorization Criteria
Initial Authorization — TMS meets medical necessity for treatment-resistant major depressive disorder when ALL of the following are met:
Retreatment Criteria
Retreatment Authorization — Retreatment (repeat acute treatment) is medically necessary when BOTH:
Delivery and Monitoring Requirements
Treatment delivery and monitoring requirements
Psychiatrist must perform first session and motor threshold determination; technician must be certified if administering subsequent sessions.
The policy identifies several clinical and technical situations in which TMS is considered inappropriate or may be denied. TMS is not appropriate for patients with active psychotic symptoms, acute suicidal risk, or catatonia. Requests are also inappropriate when the member has life‑threatening dysfunction in basic life needs or an active neurologic disorder (examples listed include encephalopathy, dementia, Parkinson’s disease, post‑stroke syndromes, increased intracranial pressure or bleeding, cerebral aneurysm, arteriovenous malformations, CSF shunts, or implants in the CNS or head/neck).
Policy history notes a September 2025 revision by the Medical Policy Workgroup that clarified language regarding ECT recommendations and added pediatric/child and adolescent indication language from the FDA. Local payer requirements may vary; the document records that Florida Blue requires a minimum treatment start age of 15 years, which may affect application of ECT‑related considerations or authorization procedures.
The policy explicitly identifies several request types that are not supported under the coverage criteria: Maintenance TMS, Intermittent Theta Burst Stimulation (iTBS), Magnetic Seizure Therapy (MST), and Navigated TMS (nTMS). It also states that requests for TMS to treat psychiatric diagnoses other than treatment‑resistant major depressive disorder — for example OCD — are not appropriate.
Within the available document excerpts there are no standalone, additional statements framed as a universal "not medically necessary" list beyond the exclusions and modality limitations already recorded. Instead, the policy history indicates substantive edits in 09/2025 (including clarifications about ECT and pediatric indications) that may change local application; implementers should refer to the full policy and any payer‑specific guidance for explicit denial language.
Diagnosis, Procedure Codes, and Rating Scales
| F32.x | Major depressive disorder |
| F33.x | Major depressive disorder |
| ICD-9 296.2x | Major depressive disorder |
| ICD-9 296.3X | Major depressive disorder |
| 90867 | CPT example unit listed for initial authorization (interpretation/testing) |
| 90868 | CPT example units listed (repetitive TMS delivery) — 36 units for initial and retreatment |
| 90869 | CPT example unit listed for initial authorization (stimulation parameter adjustment) — one unit initial; additional units require rationale |
| BDI | Beck Depression Inventory — minimum score for initial authorization: >29 |
| IDS-C | Inventory of Depressive Symptomatology Clinician-rated — minimum score for initial authorization: >36 |
| QIDS-SR | Quick Inventory of Depressive Symptomatology Self-reported — minimum score for initial authorization: >15 |
| MADRS | Montgomery-Asberg Depression Rating Scale — minimum score for initial authorization: >34 |
| PHQ-9 | Patient Health Questionnaire (PHQ-9) — minimum score for initial authorization: >19 |
Provider Requirements, Prior Authorization, and Forms
Prior authorization coding and unit requirements
Initial authorization requests must include CPT coding and unit counts exactly as specified: submit one (1) unit of CPT 90867, thirty-six (36) units of CPT 90868, and one (1) unit of CPT 90869 for the initial course. Requests for additional units of 90869 must be submitted with detailed clinical rationale; retreatment requests should request thirty-six (36) units of 90868.
Prior authorization form and payer age note
Use the Transcranial Magnetic Stimulation (TMS) Request Form provided in the policy when submitting authorization requests. Note the policy history: an external payer (Florida Blue) requires initiation age to start at 15 years, which may affect prior authorization decisions for some members.
- TMS Request Form link available in policy FORMS section.
- Florida Blue-specific start age noted in document history (age 15).
Step‑therapy: required prior antidepressant trials
Prior to authorization, document failure of two (2) adequate trials of FDA‑approved antidepressant medications from at least two (2) different antidepressant classes, or documented intolerance to such medications (two trials from at least two different classes with distinct intolerable side effects).
- Failure of two adequate trials including trials from at least two different antidepressant classes (e.g., SSRI, SNRI, TCA, MAOI).
- Or documented inability to tolerate therapeutic doses shown by two trials from at least two different classes with distinct intolerable side effects.
Other provider submission requirements (placeholder)
No additional label provided in inventory — ensure other listed provider actions are submitted with the authorization request per policy (coding/units, forms, treatment history, documentation of technician/psychiatrist roles, and rating scale scores).
- Include required coding/units and TMS Request Form when applicable.
- Attach prior medication trial documentation and rating scale scores.
- Confirm clinician roles (psychiatrist performed first treatment/motor threshold).
Required documentation to support authorization
Attach documentation of clinic/practitioner registration/certification, evidence that a board‑certified psychiatrist performed the first TMS treatment and motor threshold determination, documentation of psychiatrist oversight, and technician certification if technicians administer subsequent sessions. Also include a baseline score from one clinically accepted depression rating scale (Table 1) prior to the initial 6‑week treatment course.
- Clinic/practitioner registration/certification prior to benefit use.
- Board‑certified psychiatrist performed first treatment, cortical mapping, and motor threshold determination.
- Evidence of psychiatrist oversight for the course; technician certification when technicians administer sessions.
- Baseline depression rating scale score from Table 1 (BDI, IDS‑C, QIDS‑SR, MADRS, or PHQ‑9).
Use the TMS Request Form when requesting authorization
Providers may use the Transcranial Magnetic Stimulation (TMS) Request Form linked in the policy FORMS section when requesting authorization for TMS services.
- Form link provided in FORMS section of the policy.
Conditions that increase risk of denial or noncoverage
Requests may be considered not appropriate or medically necessary — and thus at risk for denial — for members with active substance abuse, active psychotic symptoms, acute suicidal risk, catatonia, life‑threatening dysfunction in basic life needs, active neurologic disorders (e.g., encephalopathy, dementia, Parkinson’s, post‑stroke syndromes, increased intracranial pressure/bleeding, cerebral aneurysm, AV malformations, CSF shunts, CNS/head/neck implants), psychiatric diagnoses other than treatment‑resistant depression, OCD, maintenance TMS, iTBS, MST, and navigated TMS.
- Active substance abuse (UDS confirmation may be required).
- Active psychotic symptoms or acute suicidal risk.
- Catatonia or life‑threatening dysfunction in basic life needs.
- Active neurologic disorders or non‑removable metallic implants in head/neck.
- Requests for diagnoses other than treatment‑resistant depression, OCD, maintenance TMS, iTBS, MST, or nTMS.
No other explicit denial triggers in this section; check document history
The policy text does not present additional, separate explicit denial triggers beyond the conditions listed in exclusions and not‑medically‑necessary sections; document history notes clarifications (e.g., ECT guidance) and an external payer age requirement. Verify exclusions and updated policy history when submitting requests.
- No other explicit denial triggers are listed in these document sections.
- Document history (09/2025) includes clarifications regarding ECT and notes Florida Blue age requirement of 15 years.
Permitted and Unsupported TMS Modalities
rTMS
iTBS / MST / nTMS / Accelerated TBS / Maintenance TMS
Evidence summaries cite small or limited trials for some accelerated/targeted protocols and note need for further trials and durability data.
TMS / rTMS / deep TMS
References summarize variable quality evidence for deep TMS and other modalities; policy limits coverage to modalities consistent with the criteria.
Outpatient and Site-of-Care Criteria
Outpatient TMS Level‑of‑Care Criteria
One session per day, 5 days/week for 6 weeks with 3‑week taper as specified in delivery requirements.
Treatment Frequency and Visit Limits
Definitions
Background and Rationale
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that uses time‑varying magnetic fields to influence brain activity and is used primarily to treat major depressive disorder after other treatments have failed. The policy references TMS modalities including repetitive TMS (rTMS) and deep TMS, and cites clinical evidence and guideline literature supporting rTMS for treatment‑resistant depression while noting that alternative or novel protocols (for example, accelerated or navigated approaches) have limited or investigational evidence.
Document History and Revisions
Clarified language regarding ECT recommendations and added child and adolescent indication per FDA; updated summary of evidence and revised references list (10 removed, 3 added).
Medical Policy Workgroup clarified ECT recommendation language and added pediatric (child and adolescent) indication on 09/2025.
Policy created (effective 02/2025) by Dr. J. Langlow; noted payer-specific age requirement that Florida Blue requires starting age of 15 years old.
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