Transcranial Magnetic Stimulation for Treatment of Major Depression - 2024
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Authorization and coverage parameters for use of TMS to treat treatment-resistant major depressive disorder for Lucet members and participating providers during plan year 2024.
No material clinical or coverage changes in this revision.
Coverage Criteria for Transcranial Magnetic Stimulation (TMS)
inv-01: Initial Therapy
Covered when ALL of the following are met
Initial Authorization
- Diagnosis and severity: Confirmed diagnosis of severe Major Depressive Disorder WITHOUT psychosis (ICD-9 296.2x/296.3x or ICD-10 F32.x/F33.x) with severity documented by one clinically accepted depression rating scale from Table 1 and meeting listed minimum scores.Refer to rating scale thresholds
One test chosen and used for entire treatment course.
- Prior treatment: Either failure of two trials of FDA-approved antidepressants from at least two different classes OR inability to tolerate two trials with documented intolerable side effects OR candidate for ECT where ECT outcome would not be overall superior to TMS.2 trials
Medication trials must be documented; ECT-preferred scenarios (psychosis, acute suicidality, catatonia) are exclusions for TMS.
If rating scales document lack of meaningful change, physician advisor review may be indicated.
Requests submitted on Lucet's TMS Treatment Request Form with required clinical history and baseline rating scale.
inv-02: Retreatment (Repeat acute treatment)
Retreatment (Repeat acute treatment) covered when ALL of the following are met
If relapse criteria met, repeat acute course of 5 days/week for 6 weeks (30 sessions) plus 3-week taper; frequencies <5 days/week will be reviewed for medical necessity.
The policy lists specific coverage exclusions. TMS is not covered for members with non-removable metallic objects or implants in the head or neck or with an active neurologic disorder (examples include encephalopathy, dementia, Parkinson’s disease, post-stroke syndromes, increased intracranial pressure or bleeding, cerebral aneurysm, arteriovenous malformations, CSF shunts, or central nervous system implants).
Coverage is also excluded for requests with evidence of active psychotic symptoms, for Maintenance TMS Treatment, and for treatment of OCD.
Additionally, the policy excludes specific TMS-related modalities and investigational techniques: Intermittent Theta Burst Stimulation (ITBS), Magnetic Seizure Therapy (MST), and Navigated TMS (nTMS). Finally, TMS requests for psychiatric diagnoses other than Treatment-Resistant Depression (TRD) as defined in this policy are not covered.
This portion of the document contains no explicit coverage criteria, exclusions, or not medically necessary statements in the Policies, Procedures, or Forms sections.
Requests for Maintenance TMS are explicitly excluded and considered not medically necessary. The policy further states that retreatment (repeat acute treatment) will only be considered medically necessary when prior response is documented as at least a 50% improvement on a standard depression rating scale and other retreatment criteria are met; if the member did not meet the 50% reduction threshold after the prior course, the retreatment request will be not medically necessary.
Diagnosis, Procedure Codes, and Rating Scale Thresholds
| ICD-9 296.2x | Major Depressive Disorder, single episode (documented as severe) — listed in policy |
| ICD-9 296.3x | Major Depressive Disorder, recurrent (documented as severe) — listed in policy |
| ICD-10 F32.x | Major Depressive Disorder, single episode (severe without psychosis) — listed in policy |
| ICD-10 F33.x | Major Depressive Disorder, recurrent (severe without psychosis) — listed in policy |
Authorization, Documentation, and Provider Requirements
Prior Authorization Required
Prior authorization is required via Lucet's TMS Treatment Request Form. Authorized units when TMS is found medically necessary: 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 90869 must include detailed clinical rationale.
Prior Authorization
Prior authorization is required. Ensure the TMS Treatment Request Form and supporting documentation are provided per Lucet's submission processes; timelines will follow Lucet's standard benefit determination timeframes.
Retreatment Denial Condition
If a member does not demonstrate a ≥50% improvement on a standard depression rating scale from the prior course, retreatment will not be considered medically necessary.
Policies Section — None Provided
No policies are provided in the Policies section. Providers should not assume additional Lucet policy requirements beyond those stated in this document; contact Lucet if policy detail is required for authorization decisions.
- POLICIES section: N/A
Procedures Section — None Provided
No procedures are listed in the Procedures section. Ensure all required clinical and administrative procedures (e.g., device-specific protocols, technician certification) are documented on the TMS Treatment Request Form or submitted separately as needed for review.
- PROCEDURES section: N/A
Forms Section — None Provided
No forms are provided in the Forms section. The required form for authorization is Lucet's TMS Treatment Request Form; include clinical history, past/current treatment trials, baseline and serial rating scales, and provider certification documentation.
- FORMS section: N/A
- Required submission: Lucet's TMS Treatment Request Form with clinical documentation and rating scales
Required Prior Medication Trials
Required prior medication trials: member must have failed two (2) trials of FDA‑approved antidepressants from at least two different classes, or have documented intolerance to two such trials, unless ECT candidacy or other documented reasons apply.
- Failure of two trials from at least two different antidepressant classes, OR
- Documented intolerance to two trials of antidepressants
Required Clinical Documentation and Provider Qualifications
Clinical documentation required: submit Lucet's TMS Treatment Request Form including clinical history, past and current treatment trials, baseline depression rating scale (choose one from Table 1) and serial rating scales at the required intervals, and provider/clinic certification demonstrating attending psychiatrist board certification and TMS training.
- Include baseline and serial rating scales (pre-treatment, every two weeks during 6-week course, final visit)
- Attach documentation of two prior medication trials or documented intolerance
- Provide attending physician board certification and TMS training/certification
- Provide clinic/practitioner registration documentation if requested
Not Medically Necessary Conditions
Not medically necessary / excluded uses include: Maintenance TMS, treatment of OCD, Intermittent Theta Burst Stimulation (ITBS), Magnetic Seizure Therapy (MST), Navigated TMS (nTMS), and TMS for psychiatric diagnoses other than treatment‑resistant depression.
- Maintenance TMS — not covered
- OCD treatment — not covered
- ITBS — not covered
- MST — not covered
- nTMS — not covered
- TMS for DSM-5 psychiatric diagnoses other than TRD — not covered
Background on TMS
Transcranial Magnetic Stimulation (TMS) is a noninvasive neuromodulation technique that delivers electromagnetic pulses to induce cortical neuronal activity. Clinical descriptions distinguish frequency-based approaches, commonly categorized as fast TMS and slow TMS, and note general adverse effects such as local discomfort and rare seizure risk.
For operational clarity in this policy, "fast" TMS refers to frequencies of 3–20 Hz while "slow" TMS is defined as frequency <1 Hz.
Definitions and Terminology
Level of Care and Setting
TMS Modalities and Techniques
inv-24: TMS (repetitive TMS)
Deep TMS for OCD and other non-TRD psychiatric indications are excluded.
Session Limits and Authorized Units
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