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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral Healthlucet TMS Coverage Prior Auth Policy Update | Open…
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    CurrentlucetPolicy 20.5.001

    Transcranial Magnetic Stimulation for the Treatment of Major Depression

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    Policy governing coverage and medical necessity criteria for repetitive TMS treatment of treatment‑resistant major depressive disorder for Lucet members and participating providers.

    Policy Summary
    Payerlucet
    PolicyTranscranial Magnetic Stimulation for the Treatment of Major Depression
    Policy CodePolicy 20.5.001
    Change TypeNo material change
    Effective DateOct 1, 2014
    Last ReviewOct 1, 2024
    Next Review Date
    Key ActionSubmit prior authorization specifying 1 unit 90867, 36 units 90868, and 1 unit 90869 with documentation of two failed antidepressant trials or documented intolerance.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    18-70
    age range eligible
    6 weeksinitial acute duration
    2 failedrequired med trials
    36typical 90868 units
    CMO approvalexceptions pathway

    Coverage and Medical Necessity Criteria

    inv-01: Initial Authorization (Medical Necessity for TRD)

    Covered when ALL of the following are met:

    Initial Authorization: (1) Confirmed diagnosis of severe Major Depressive Disorder WITHOUT psychosis (ICD‑9: 296.2x/296.3x; ICD‑10: F32.x/F33.x) with severity documented by one clinically accepted depression rating scale from Table 1; (2) Member age between 18 and 70; (3) Any one of: failure of two trials of FDA‑approved psychopharmacologic agents from at least two different antidepressant classes; OR documented inability to tolerate therapeutic doses demonstrated by two trials from at least two different antidepressant classes with distinct intolerable side effects; OR TMS judged by the provider to be a less invasive option than ECT or the member declines ECT.see Table 1

    See policy for required documentation, serial rating scales, and provider/training requirements.

    inv-02: Treatment Delivery Requirements

    Covered when ALL of the following delivery conditions are met:

    Delivery: TMS is administered using an FDA‑approved device; a board‑certified psychiatrist with documented training in TMS must personally perform the first treatment including cortical mapping and motor threshold (MT) determination and re‑determination as required; subsequent treatments may be provided by the psychiatrist or a certified TMS technician; clinics/practitioners must be registered with Lucet prior to providing services.

    Documentation of clinician certification/clinic registration required.

    Schedule: One treatment session per day, five consecutive days per week for six consecutive weeks (initial acute course). Immediately following the six‑week period, taper as follows: post‑acute week 1 = 3 sessions; week 2 = 2 sessions; week 3 = 1 session.

    Standardized depression rating scales must be administered at baseline prior to the acute course, then every two weeks during the six‑week period, and a final test at the last visit; use a single scale consistently.

    inv-03: Retreatment / Repeat Acute Course

    Retreatment is medically necessary when BOTH of the following are met:

    Retreatment criteria: (a) Member continues to meet all initial TMS treatment requirements; (b) Member previously responded to a prior TMS course with ≥50% improvement on a standard depressive symptom rating scale (per Table 1) AND at least 90 days have elapsed since termination of the prior TMS treatment course.>=50% improvement; >=90 days since prior course

    Retreatment authorization typically corresponds to 36 units of CPT 90868.

    Requests for TMS that fall outside treatment‑resistant major depressive disorder are considered not appropriate and may be denied. Specifically, requests for Maintenance TMS, Intermittent Theta Burst Stimulation (iTBS), Magnetic Seizure Therapy (MST), and Navigated TMS (nTMS) are listed as exclusions. The policy also excludes TMS for treatment of OCD, for psychiatric diagnoses in the DSM other than treatment‑resistant depression, and for members with non‑removable metallic objects or implants in the head/neck or active neurologic disorders (e.g., encephalopathy, dementia, Parkinson’s disease, post‑stroke syndromes, increased intracranial pressure/bleeding, cerebral aneurysm, AV malformations, CSF shunts, CNS/head/neck implants).

    Limitations in the evidence base are noted for maintenance and some alternative TMS protocols: published maintenance schedules (e.g., TMS every 2–4 weeks for many months or years) derive largely from reviews and uncontrolled series and the review authors emphasized that well‑designed controlled studies are needed. Similarly, for other indications the literature includes small sample sizes and observational reports, indicating limited high‑quality evidence to support routine coverage outside the policy’s specified indications.

    Use of TMS for conditions other than treatment‑resistant major depressive disorder is not considered medically necessary under this policy. This includes TMS for OCD, maintenance treatment, iTBS, MST, and nTMS. Although deep TMS (dTMS) has shown benefit for some patients with OCD in real‑world series, and extended dTMS courses (beyond 29 sessions) may further reduce symptoms with onset often within 20 sessions, these findings are not sufficient to change the policy’s exclusion of routine coverage for OCD or other non‑TRD psychiatric diagnoses; formal controlled evidence and replication are still needed.

    Billing and Diagnosis Codes

    Authorized CPT codes and typical unit countsCPTCovered
    90867E/M with TMS initial
    90868TMS session (repetitive)
    90869TMS booster/complex session
    Diagnosis codes for eligible conditionICD-10 | ICD-9Covered
    ICD-9: 296.2x, 296.3xMajor Depressive Disorder (single/recurrent)
    ICD-10: F32.x, F33.xMajor Depressive Disorder (single/recurrent)
    Minimum depression rating scale scores for initial authorization
    Beck Depression Inventory (BDI)Minimum score for initial authorization: >29
    Inventory of Depressive Symptomatology — Clinician (IDS-C)Minimum score for initial authorization: >36
    Quick Inventory of Depressive Symptomatology — Self‑Report (QIDS‑SR)Minimum score for initial authorization: >15
    Montgomery‑Åsberg Depression Rating Scale (MADRS)Minimum score for initial authorization: >34
    Patient Health Questionnaire (PHQ‑9)Minimum score for initial authorization: >19

    Prior Authorization, Documentation, and Provider Requirements

    Prior Authorization

    Prior authorization: specify CPT units for initial and retreatment

    Initial authorization requests must specify one (1) unit of CPT 90867, thirty-six (36) units of CPT 90868, and one (1) unit of CPT 90869. Requests for additional units of CPT 90869 must be submitted with detailed clinical rationale. Retreatment (repeat acute course) authorizations specify 36 units of CPT 90868.

    • Initial authorization: 1 unit 90867; 36 units 90868; 1 unit 90869.
    • Additional 90869 units require detailed clinical rationale.
    • Retreatment authorization: 36 units of 90868.
    Prior Authorization

    Use the TMS Request Form; exceptions need CMO/designee sign-off

    Use the Transcranial Magnetic Stimulation (TMS) Request Form when submitting authorization requests. Any requested exception to the policy must be approved by the Lucet Chief Medical Officer or their designee per the administrative exception pathway.

    • Form available: Transcranial Magnetic Stimulation (TMS) Request Form.

    Clinical Background and Evidence Summary

    Transcranial Magnetic Stimulation (TMS) is a noninvasive neuromodulation technique used to treat adults with treatment‑resistant major depressive disorder (TRD). TMS delivers magnetic pulses to targeted cortical regions to modulate neuronal activity; treatment is typically delivered as an outpatient course with cortical mapping and determination of a motor threshold performed at the initial session by a trained psychiatrist. The policy specifies an acute treatment schedule of one session per day, five days per week for six weeks with a defined taper, and requires standardized depression rating scales for baseline and ongoing monitoring during the acute course.

    Key Definitions

    Treatment‑resistant major depressive disorder (TRD) — definition and criteria
    Definition of TRDMajor Depressive Disorder without psychosis that has failed to respond to two adequate pharmacologic treatment trials from at least two different antidepressant classes, OR documented intolerance to such medications, with severity documented by a clinically accepted depression rating scale.
    Age requirementMember age between 18 and 70 years for initial authorization.
    Severity documentationSeverity must be documented by one accepted depression rating scale meeting Table 1 minimum prior to treatment.
    Prior treatment requirementFailure of two trials of FDA‑approved antidepressant agents from at least two different classes, or documented intolerance to such medications.
    Motor Threshold (MT) — clinical measurement used to guide stimulation
    Definition

    Setting and Level of Care

    inv-23: Outpatient

    Outpatient level of care: Admission to the TMS outpatient program requires: confirmed diagnosis of severe MDD without psychosis; age 18–70; severity meeting Table 1 threshold; failed or intolerant to the required medication trials (or TMS preferred to/declined ECT); initial session performed by a qualified psychiatrist and clinic registered with Lucet.see Table 1

    Treatment is delivered outpatient; first session includes motor threshold determination.

    Continued treatment: Serial standardized depression rating scales demonstrate meaningful improvement or acceptable clinical progress. If rating scales document lack of meaningful change or worsening, review by a physician advisor is indicated.rating scales every 2 weeks during acute course

    If nonresponse, consider discontinuation.

    TMS Modalities Covered / Not Covered

    inv-24: TMS (repetitive rTMS, conventional protocols)

    rTMS criteria: Use an FDA‑approved device and follow the initial acute schedule and taper per policy; meet diagnostic, age, and medication trial requirements; serial standardized depression rating scales for monitoring must be performed as specified.see policy

    Deep TMS, accelerated protocols, and theta‑burst modalities are discussed in evidence but some are excluded or not approved by this policy.

    inv-25: TMS (rTMS, dTMS)

    Evidence summary: Deep TMS (dTMS) has demonstrated safety and efficacy in OCD and has regulatory approvals in some contexts; rTMS shows promise in treatment‑resistant OCD but requires larger replication and maintenance studies; meta‑analyses suggest potential effectiveness of TMS for GAD and PTSD. In real‑world dTMS for OCD the onset of improvement often occurs within ~20 sessions and extended courses (>29 sessions) may provide further symptom reduction.

    These evidence points inform modality discussion but coverage for indications other than TRD is excluded by the policy.

    Session Frequency and Course Length

    TMS session — initial course and tapering schedule
    Initial acute course scheduleOne session per day, five consecutive days per week for six consecutive weeks (initial acute course).
    Tapering week 1After initial six‑week course: Week 1 = 3 treatment sessions.
    Tapering week 2After initial six‑week course: Week 2 = 2 treatment sessions.
    Tapering week 3After initial six‑week course: Week 3 = 1 treatment session.
    Policy Summary
    Payerlucet
    PolicyTranscranial Magnetic Stimulation for the Treatment of Major Depression
    Policy CodePolicy 20.5.001
    Change TypeNo material change
    Effective DateOct 1, 2014
    Last ReviewOct 1, 2024
    Next Review Date
    Key ActionSubmit prior authorization specifying 1 unit 90867, 36 units 90868, and 1 unit 90869 with documentation of two failed antidepressant trials or documented intolerance.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaBilling and Diagnosis CodesPrior Authorization, Documentation, and Provider RequirementsClinical Background and Evidence SummaryKey DefinitionsSetting and Level of CareTMS Modalities Covered / Not CoveredSession Frequency and Course Length
  1. Exceptions require approval by the Lucet Chief Medical Officer or designee.
    2. Step Therapy

    Medication trials required: two failed trials from ≥2 classes or documented intolerance

    Members must have failed two (2) adequate trials of FDA‑approved antidepressant medications from at least two (2) different antidepressant classes, or have documented inability to tolerate therapeutic doses demonstrated by two trials from at least two different classes with distinct intolerable side effects.

    • Failure of two trials from at least two different antidepressant classes (e.g., SSRI, SNRI, TCA, MAOI).
    • Or documented intolerance: two trials from at least two classes with distinct intolerable side effects.
    Note

    Prior treatment context and evidence limitations for dTMS/rTMS

    Document prior treatment context: dTMS evidence derives from patients who failed multiple medications and CBT, but published analyses note small sample sizes and lack of controlled monitoring of prior treatments; rTMS evidence for some indications requires larger replication and long‑term/maintenance study.

    • dTMS study efficacy shown in patients who previously failed multiple medications and CBT; limitations include small sample size and lack of controlled monitoring.
    • rTMS for OCD is promising but needs large replication and evaluation of long‑term/maintenance effects.
    Documentation Required

    Required documentation: registration, psychiatrist training, MT, and rating scales

    Required documentation must include clinic/practitioner registration/certification, evidence that a board‑certified psychiatrist trained in TMS personally performed the first treatment including cortical mapping and motor threshold (MT) determination (and re‑determination as required), baseline and serial standardized depression rating scale scores (baseline prior to acute course and every two weeks during the six‑week acute course), and documentation of prior antidepressant trials or documented intolerance.

    • Clinic/practitioner registration/certification with Lucet prior to benefit use.
    • Board‑certified psychiatrist trained in TMS must personally perform the first TMS treatment including cortical mapping and MT determination (and re‑determination).
    • Baseline depression rating score meeting Table 1 minimum and serial scores every two weeks during acute course.
    • Documentation of prior antidepressant trials (two trials from ≥2 classes) or documented intolerance.
    Documentation Required

    Required form: TMS Request Form

    Provide the Transcranial Magnetic Stimulation (TMS) Request Form with authorization submissions; this organizational form is listed as the form available for use.

    • Form name: Transcranial Magnetic Stimulation (TMS) Request Form.
    Denial Risk

    Denial triggers: excluded modalities and non‑covered indications

    Do not request coverage for Maintenance TMS, iTBS, Magnetic Seizure Therapy (MST), Navigated TMS (nTMS), treatment for OCD, or TMS for DSM diagnoses other than treatment‑resistant depression — these uses are considered not appropriate or not medically necessary and may be denied.

    • Exclusions include: Maintenance TMS, iTBS, MST, nTMS.
    • Requests for OCD or DSM diagnoses other than treatment‑resistant depression are excluded/not appropriate.
    Prior Authorization

    Exceptions require CMO/designee approval (administrative exception pathway)

    If requesting an exception to the policy, submit for approval through the administrative exception pathway — exceptions must be approved by the Lucet Chief Medical Officer or their designee.

    • All exceptions require approval by the Lucet Chief Medical Officer or designee.
    • Follow the administrative exception process when submitting clinical justification.
    Motor Threshold (MT) is the clinical measurement obtained during the initial TMS session (cortical mapping and motor threshold determination) used to guide stimulation dosing.
    Who performs MT determinationA board‑certified psychiatrist trained in TMS must personally perform the first treatment including cortical mapping and MT determination.
    Re‑determinationRe‑determination of MT is required as specified during initial treatment and when clinically indicated.
    dTMS — deep TMS summary and regulatory status for OCD
    DescriptionDeep transcranial magnetic stimulation (dTMS) has been shown to be safe and effective as a treatment alternative for obsessive‑compulsive disorder (OCD).
    EvidenceEfficacy demonstrated in a double‑blind multicenter dTMS study in OCD patients who previously failed multiple medications and CBT.
    Regulatory statusdTMS has recently received regulatory approvals for treatment of OCD.
    rTMS — repetitive TMS summary and evidence for OCD
    DescriptionRepetitive transcranial magnetic stimulation (rTMS) appears promising for treatment‑resistant OCD but evidence is limited.
    Evidence gapsThere is a pressing need for large replication studies and evaluation of long‑term effects and maintenance protocols for rTMS in OCD.
    Clinical implicationCurrent rTMS data for OCD are preliminary and should be interpreted with caution pending larger trials.