CurrentlucetPolicy N/A

Transcranial Magnetic Stimulation (TMS) prior authorization form/process

Form and instructions for requesting authorization for TMS services, including required clinical documentation (medication trials, psychotherapy, rating scales) and submission/fax details; intended for providers submitting authorization requests for behavioral health members.

Policy Summary

Payerlucet

PolicyTranscranial Magnetic Stimulation (TMS) prior authorization form/process

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the authorization form with demographics, at least two antidepressant trials, one episode of evidence‑based psychotherapy, and baseline depression rating scales, then fax to the listed plan or Lucet review team.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

at least 2required antidepressant trials documented

at least 1evidence-based psychotherapy episode required

90867CPT 90867

90868CPT 90868

90869CPT 90869

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Coverage Criteria for TMS Authorization

Medical necessity documentation criteria

Covered when ALL of the following are met and documented on the form:

TMS authorization prerequisites: 1) Primary diagnosis and current episode duration documented with DSM-5 or ICD-10 codes; 2) At least two antidepressant medication trials during the current depressive episode with start/end dates, reason for discontinuation (lack of efficacy or adverse reaction), and documented percent response or adverse reactions; 3) At least one full episode of evidence-based psychotherapy (e.g., DBT, CBT, ITP) documented with clinician name, start and end dates, and percent response; 4) Pre-treatment depression rating scale scores recorded (PHQ-9, BDI, MADRS, CGI, IDS-SR, IDS-C); 5) Completion of provider and patient demographic and provider identifiers (referring physician, NPI/Tax ID, contact information); 6) Submission via the listed fax numbers to the appropriate plan or Lucet internal Behavioral Health Benefit Review team.

These elements are required to evaluate medical necessity for TMS.

Authorization may not be required for certain Blue Cross Blue Shield plans and groups listed on the form. Specifically, BCBS Alabama (except Medicare and Southern Company group), BCBS Kansas (except Medicare), and BCBS Arkansas Federal Employee Program (FEP) are identified as not requiring authorization. For all other plans or when in doubt, submit the completed TMS authorization form and required clinical documentation per the plan-specific submission instructions (fax to the number listed for the member's plan or Lucet internal Behavioral Health Benefit Review team) to determine whether prior authorization is needed.

Requests will not be approvable if required clinical elements are missing from the form. The form requires documentation of at least two antidepressant trials during the current depressive episode with start/end dates and reasons for discontinuation (lack of efficacy or adverse reaction). It also requires documentation of at least one full episode of an evidence-based psychotherapy (e.g., CBT, DBT, ITP) with clinician, dates, and percent response, and pre-treatment depression rating scale scores (for example, PHQ-9, BDI, MADRS, CGI, IDS-SR/C). Absence of these elements may render the request insufficient for medical necessity review and lead to denial.

Billing Codes and Coding Rules

TMS-related CPT codes for approved requestsCPTCovered

90867	One unit per course of treatment.
90868	36 units per course of treatment.
90869	Approval of one unit will be provided.

Antidepressant trials — requirement

RequirementAt least 2 documented antidepressant medication trials during the current depressive episode (start and end dates required)

Documentation detailsInclude medication name, maximum daily dose, start/end dates, percent response or disabling adverse reaction

Reason for discontinuationDocument if discontinued due to lack of efficacy or adverse reaction

Episode specificityTrials must be during the current depressive episode

Psychotherapy — requirement

RequirementAt least 1 full episode of evidence-based psychotherapy documented (e.g., CBT, DBT, ITP)

Provider Instructions and Submission Requirements

Prior Authorization

Prior authorization and CPT coding

Authorization is not required for certain Blue Cross Blue Shield plans listed on the form (e.g., BCBS Alabama except Medicare and Southern Company group; BCBS Kansas except Medicare; BCBS Arkansas FEP). For all other members, submit the completed TMS authorization form with the required clinical documentation; approved requests will include CPT codes 90867 (one unit per course), 90868 (36 units per course), and 90869 (one unit) as noted on the form.

If member’s plan appears on the “Authorization is not required for” list, follow plan-specific instructions.
If authorization is required, include the completed form and clinical documentation for review.

Step Therapy

Medication trial requirement

Document at least two antidepressant medication trials during the current depressive episode on the form, including start and end dates, reason for discontinuation (lack of efficacy or adverse reaction), and percent response or disabling adverse reaction details.

Definitions and Rating Scales

Depression rating scales — baseline assessment

Accepted instrumentsPHQ-9, BDI, MADRS, CGI, IDS-SR, IDS-C

Multiple scales permittedMay record more than one pre-treatment depression rating scale and score

Required entriesInclude score and date for each instrument used

PurposeUsed to document baseline severity and track response

Antidepressant trials — definition

DefinitionAntidepressant medication trials during the current depressive episode with start and end dates and reason for discontinuation documented

Transcranial Magnetic Stimulation (TMS) Treatment

TMS — Treatment modality criteria and coding note

Top-level requirements and coding note for Transcranial Magnetic Stimulation (TMS) authorization:

TMS treatment modality criteria: Document diagnostic codes, episode duration, at least two antidepressant medication trials during the current depressive episode, at least one full episode of evidence-based psychotherapy, and baseline pre-treatment depression rating scale(s). Include referring provider and patient identifiers and submit the completed form per instructions.

Required documentation supports authorization determination for TMS.

TMS coding note: If the TMS request is found medically necessary, include CPT codes 90867 (one unit per course), 90868 (36 units per course), and 90869 (one unit approval) as specified on the form.

Authorization determination drives inclusion of these CPT codes and units.

Background

This form documents the clinical history and treatments necessary to evaluate Transcranial Magnetic Stimulation (TMS) for patients with depressive disorders. It captures patient demographics and provider identifiers, the primary diagnosis and current episode duration (DSM-5 or ICD-10), detailed antidepressant medication trial history (must include at least two trials during the current episode with dates, doses, efficacy, and adverse reactions), and evidence-based psychotherapy history (must include at least one full episode with clinician, dates, and percent response). Pre-treatment depression rating scale scores (such as PHQ-9, BDI, MADRS, CGI, IDS-SR/C) and documentation of current functional impairment are also required to assess baseline severity and treatment response potential. Completed forms should be returned via the fax number shown for the member’s plan or to the Lucet Behavioral Health Benefit Review team as directed.

Policy Summary

Payerlucet

PolicyTranscranial Magnetic Stimulation (TMS) prior authorization form/process

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Required fieldsDocument type of therapy, clinician name, start and end dates, and percent response/results

ExamplesCognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Interpersonal Therapy (ITP)

Functional statusInclude documentation of current levels of impairment (work, school, social, family, sleep, mood) where applicable

List each antidepressant trial with Start Date and End Date.

Indicate if discontinued for lack of efficacy or adverse reaction and document efficacy/percent response.

Documentation Required

Required documentation for authorization

Complete all required form fields: patient demographics and insurance, requesting physician information (including NPI and Tax ID), TMS information (referral date, TMS start date, primary diagnosis, current episode duration), antidepressant trial details, psychotherapy episode details, and pre-treatment depression rating scale scores.

Patient name, phone, insurance policy number, date of birth.
Requesting physician name, phone, address, Tax ID, NPI.
TMS referral date, TMS start date, primary diagnosis and episode duration.
Antidepressant trial tables (>=2 trials) and psychotherapy episode documentation (>=1 full episode).
Pre-treatment depression rating scale(s) with scores and dates (PHQ-9, BDI, MADRS, CGI, IDS-SR/C, etc.).

Billing Rule

Submission instructions

Return the completed form via fax to the appropriate fax number for the member’s plan or to Lucet’s Internal Behavioral Health Benefit Review team when applicable; verify benefits and authorization requirements using the customer service number on the member’s ID card.

Lucet employee cases (Internal Behavioral Health Benefit Review): fax 816-416-7788 or 816-237-2364 as directed.
Follow the fax number listed for the member’s specific plan on the form.

Denial Risk

Insufficient clinical trials/documentation

Failure to document the required antidepressant medication trials (at least two during the current depressive episode) and at least one full episode of evidence‑based psychotherapy, including dates, clinician, and response, may lead to denial of the TMS request.

Missing antidepressant trial dates, reasons for discontinuation, or percent response risks denial.
Missing psychotherapy episode documentation (type, clinician, dates, % response) risks denial.

Medication name, maximum daily dose, start/end dates, percent response or disabling adverse reaction

Discontinuation reasonsSpecify if discontinued for lack of efficacy or adverse reaction

Number requiredDocument at least two separate antidepressant trials during the current episode