Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder
Customize your policy alerts
Sign up for mhn Policy CP.BH.201 alerts
Get alerted when Policy CP.BH.201 changes without checking for updates manually.
Monitor payer policy activity
Medical necessity criteria, coding, and coverage stance for use of deep transcranial magnetic stimulation to treat obsessive-compulsive disorder for members/enrollees of the payer.
Changed the allowed initial number of sessions from 30 to up to 36 sessions (recommended 5 days/week for 6 weeks with optional six taper sessions).
Updated contraindication list by removing several relative contraindications (history of seizures, severe dementia, severe cardiovascular disease, active suicidal ideation with intent) and replacing other items (e.g., substance use remission requirement).
Clarified medication failure criteria to require lack of clinically significant response to four trials from at least two agent classes, with at least two SSRI/SNRI/clomipramine or atypical antipsychotic trials of >=12 weeks.
Specified FDA-cleared devices acceptable for treatment (examples listed).
Changed response thresholds and retreatment response criteria from 25%/50% reductions to 30% reductions in some sections.
Request is for up to 36 sessions (Recommended schedule is for five days a week for six weeks, with an optional six sessions for tapering).
Removed certain relative contraindications (history of seizures, severe dementia, severe cardiovascular disease, active suicidal ideation with intent) and removed 'pregnancy' and 'neurological disease or head injury' from the contraindication list.
New CPT/HCPCS codes added: 97014 and 97032 for electrical stimulation modalities.
Coverage and Medical Necessity Criteria
Initial Therapy
Covered when ALL of the following are met for initial treatment:
Maintenance Therapy
Maintenance therapy:
Retreatment
Retreatment (case-by-case review):
Requests for retreatment are subject to individual medical director review and documentation requirements.
Coverage with criteria
Covered when criteria in the policy are met; notable operational criteria and limits updated during review.
See initial, maintenance, and retreatment sections for full clinical criteria and specific contraindications; prior authorization and documentation requirements apply.
Explicit exclusions include members with conductive or ferromagnetic or other magnetic‑sensitive metals implanted or embedded in the head or neck within 30 cm of the dTMS H7 coil placement (other than dental fillings). Examples called out in the policy include cochlear implants, implanted electrodes/stimulators, aneurysm clips or coils, stents, bullet fragments, metallic tattoo dyes, and vagus nerve stimulators. The policy also excludes members with other implanted stimulators that are controlled by or use electrical or magnetic signals (for example: deep brain stimulation systems, cardiac pacemakers, cardioverter defibrillators, intracardiac lines, medication pumps).
The contraindication list was revised to consolidate and remove several prior relative contraindications. Notable changes include removal of prior items such as history of seizures, severe dementia, severe cardiovascular disease, and active suicidal ideation with intent. The policy language was also clarified regarding supervision and wording for substance‑use remission, and redundant items were combined where appropriate.
Maintenance dTMS for obsessive‑compulsive disorder is considered not medically necessary because the policy finds there is insufficient peer‑reviewed literature to support routine maintenance treatment with dTMS at this time.
During the policy update, the following previously listed items were removed from the contraindication list: pregnancy and neurological disease or head injury. In addition, the policy clarified the substance‑use criterion to require less than three months of substantiated remission from a substance use disorder as a contraindication, and removed other relative contraindications as noted above.
Coding and Severity Definitions
| 90867 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery, and management. |
| 90868 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session. |
| 90869 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management. |
| 97014 | Application of a modality to 1 or more areas; electrical stimulation (unattended). |
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required: age, DSM diagnosis, failed trials, and contraindications
Prior authorization is required for dTMS for OCD and must document the member is ≥18 years old, a DSM-confirmed diagnosis of OCD, failure of the required medication and CBT/ERP trials, and absence of listed contraindications. The request must also identify the planned FDA‑cleared device and coil.
- Member is ≥ 18 years old (I.A)
- Confirmed DSM diagnosis of OCD (I.B)
- Failed combination of multiple medication trials plus CBT and/or ERP for ≥12 weeks during current episode (I.D)
- No contraindications present (I.H)
- Planned use of an FDA‑cleared device/coil (I.F)
Prior authorization requests: session count and recommended schedule
Submit prior authorization for up to 36 sessions; include the recommended treatment schedule (five days per week for six weeks) and note optional six taper sessions when applicable. Requests should be limited to the specified session count.
- Request is for up to 36 sessions (I.E)
- Recommended schedule: five days/week × 6 weeks with optional 6 taper sessions (I.E; chunk 18)
dTMS reserved for members who failed first‑line CBT/ERP and pharmacotherapy
dTMS is reserved for members who have failed first‑line treatments. Providers must document adequate CBT/ERP and required pharmacotherapy trials per the policy before authorization will be approved.
- Failed combination of multiple medication trials plus CBT and/or ERP for at least 12 weeks during the current episode (I.D)
- TMS is an add‑on after trials of ERP and/or medication per guideline recommendations (International OCD Foundation)
Provider responsibilities: supervision and device use
Include any remaining provider‑action specifics recorded in the policy (e.g., supervision and device requirements). Direct supervision must be provided by a licensed psychiatrist unless state scope of practice allows other providers to supervise.
- Direct supervision of treatment by a licensed psychiatrist unless state scope allows otherwise (I.G)
- Treatment administered using an FDA‑cleared device in accordance with labeled indications (I.F)
Required documentation: diagnosis, Y‑BOCS, prior therapy records, and device
Documentation must include a DSM‑confirmed OCD diagnosis, baseline and follow‑up Y‑BOCS scores, and detailed records of prior CBT/ERP and pharmacologic trials (including agents, classes, durations, and reasons for failure or intolerance). Also document the FDA‑cleared device and coil used.
- DSM‑confirmed OCD diagnosis (I.B)
- Baseline and response Y‑BOCS scores (I.D.1; Y‑BOCS description)
- Records of prior CBT/ERP and pharmacologic trials, including four trials from ≥2 classes and durations (I.D.2)
- Device used (FDA‑cleared device/coil) (I.F)
Document response duration (6 months) for retreatment
For continuation or retreatment considerations, provide documentation of prior treatment response durability — specifically a documented 6‑month duration of response where applicable. This supports retreatment decisions per policy.
- Retreatment requires prior response of at least 30% drop from baseline with a documented 6‑month duration (III.C)
- Policy references documented 6‑month duration of response in background/retreatment context
Denial risks: common reasons requests may be denied
Requests may be denied for specific reasons: member age <18, lack of a confirmed DSM diagnosis of OCD, insufficient prior treatments (no adequate CBT/ERP or required medication trials), presence of significant comorbid psychiatric disorders, or listed contraindications (e.g., metal implants, other implanted stimulators, <3 months remission from substance use disorder, known non‑adherence).
- Member is under 18 (I.A)
- No confirmed DSM diagnosis of OCD (I.B)
- Insufficient prior treatment: did not fail required medication + CBT/ERP trials for ≥12 weeks (I.D)
- Presence of other mental health disorders (I.H.5)
- Contraindications such as conductive/ferromagnetic implants or other implanted stimulators, less than 3 months remission from substance use disorder, known non‑adherence (I.H.1–4)
Session limit enforcement: up to 36 sessions and schedule adherence
Requests that exceed the approved session limit (policy allows up to 36 sessions for the initial course) or that do not follow the recommended schedule (five days/week × 6 weeks with optional taper) may be denied. Ensure authorization requests and clinical documentation match the session count and schedule.
- Policy allows up to 36 sessions for the initial course (I.E)
- Recommended schedule: five days/week for six weeks with optional six taper sessions (I.E)
- Requests exceeding the approved number of sessions or not following recommended schedule may trigger denial (denial risks/module language)
Background and Clinical Context
Obsessive‑compulsive disorder (OCD) is characterized by intrusive obsessions and repetitive compulsions that impair functioning. First‑line treatments include evidence‑based psychotherapy—particularly cognitive‑behavioral therapy with exposure and response prevention (CBT/ERP)—and serotonin‑reuptake pharmacotherapy (SSRIs/SNRIs) or clomipramine, often with augmentation strategies when indicated. Per the policy, dTMS is positioned as a later‑line option for adults (age ≥18) with a confirmed DSM diagnosis of OCD who have not achieved an adequate response to recommended first‑line therapies: inadequate clinical response after four pharmacologic trials representing at least two different agent classes (with at least two SSRI/SNRI/clomipramine or atypical antipsychotic augmentation trials of ≥12 weeks), and an adequate trial of CBT/ERP. dTMS treatment is specified to use an FDA‑cleared device and is limited to an initial request of up to 36 sessions (recommended 5 days/week for 6 weeks with an optional six‑session taper).
Definitions and Measurement Tools
Treatment Modalities and Device Information
TMS/dTMS
Examples of FDA‑cleared devices and coils are listed in the policy (e.g., Brainsway H7, MagVenture cool DB80, Magstim Horizon 3.0, NeuroStar).
TMS
Device clearances and key trials are cited in the policy references.
Session Limits and Visit Frequency
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.