Transcranial Magnetic Stimulation (TMS) prior authorization and requirements
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This document governs the authorization intake, required documentation, and billing guidance for Transcranial Magnetic Stimulation (TMS) requests for Lucet-managed plans; it affects providers submitting TMS authorization requests and internal benefit review teams.
No material clinical or coverage changes in this revision.
Coverage Criteria for TMS
Initial TMS Authorization
Covered when ALL of the following are met and documented:
Form fields required
Explicit medication trial data required as on the form
Required psychotherapy trial documented on the form
Baseline severity metrics required; scores and dates must be provided
Authorization is not required for certain payer groups. Examples listed on the intake form include BCBS Alabama (except Southern Company group), BCBS Arkansas Federal Employee Program (FEP), and BCBS Kansas (except Medicare). Providers must verify benefits and prior‑authorization requirements for each member per the member's ID card, as some groups are exempt from the standard prior‑authorization process.
All member information fields on the authorization form must be fully completed. The form states that Member's Name, Date of Birth, Insurance ID Number, and Member's Phone Number must be provided; failure to complete these required fields will cause the form to be returned. Incomplete documentation does not satisfy medical necessity requirements and may prevent authorization.
Coding and Clinical Items
Provider Submission & Documentation Requirements
Prior authorization and submission instructions
Prior authorization is required per payer rules except for listed exceptions; verify benefits via the customer service number on the member's ID card and submit the completed TMS authorization form to the appropriate fax number or customer service per the member's plan.
- Authorization not required for specified groups listed on the form (see exceptions).
- Use the customer service number on the member's insurance ID card for verification of benefits, eligibility, authorization requirements, and allowable codes.
- Return the completed form by fax to the appropriate number for the member's plan (e.g., Lucet Employee: 816-416-7788; Internal BH Benefit Review: 816-237-2364).
Antidepressant medication trials required (>=2)
Document at least two adequate antidepressant medication trials during the current depressive episode, including medication name, maximum daily dose, start and end dates, reason for discontinuation (lack of efficacy or adverse reaction), and percent response or disabling adverse reaction.
- Complete the medication trial fields on the form for Trial 1 and Trial 2 (and Trial 3 if applicable).
- Record whether discontinuation was due to lack of efficacy or an adverse reaction and document percent response.
Required documentation to support TMS authorization
Submit the completed TMS authorization form with member and provider identifying information, primary and other diagnoses, TMS start date, current episode duration, documentation of required medication and psychotherapy trials, current impairment levels, and at least one pre‑treatment depression rating scale.
- Member name, DOB, insurance ID, and phone number must be completed.
- Referring physician name, referral date, primary and other diagnoses, TMS start date, and current episode duration.
- Documentation of at least two antidepressant trials and at least one full episode of evidence‑based psychotherapy (clinician name, start/end dates, results).
- At least one pre‑treatment depression rating scale (PHQ-9, BDI, MADRS, CGS, IDS‑SR, or IDS‑C) with score and date.
Risk of return or denial for incomplete form
Incomplete or missing member information or incomplete form fields may cause the form to be returned or denied; all member fields must be completed and legible.
- Ensure Member's Name, Date of Birth, Insurance ID Number, and Member's Phone Number are filled in; forms with missing member information will be returned.
- Type or print neatly and complete all designated fields, including numerical diagnosis codes from DSM‑5 or ICD‑10.
Background
Transcranial Magnetic Stimulation (TMS) is presented on the form as a treatment option for depressive disorders when there has been an inadequate response to pharmacotherapy and psychotherapy. The intake collects clinical details necessary to determine medical necessity, including the primary diagnosis, duration of the current depressive episode, documentation of at least two antidepressant medication trials during the current episode (with medication name, dose, dates, reason for discontinuation, and response), documentation of at least one full episode of evidence‑based psychotherapy (for example DBT, CBT, ITP) and clinician details, and baseline severity and functioning measures to support the authorization decision.
Definitions
Treatment Modalities
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