Prior Authorization Required

Prior authorization is required for initial and retreatment TMS requests. Initial requests for adults (≥18) may be authorized for up to 36 sessions (recommended schedule five days/week for six weeks with optional six taper sessions). Requests for additional or retreatment sessions are reviewed case-by-case by medical director; limits on Theta Burst Stimulation (TBS) apply (more than 30 TBS sessions may be denied). Maintenance TMS (ongoing/recurring maintenance courses) is considered not medically necessary and will be denied.

• Initial prior authorization required; initial request reviewed for up to 36 sessions (note: recommended 5 days/week × 6 weeks; optional 6 taper sessions)
• Retreatment/additional sessions reviewed case-by-case by medical director
• Requests >30 TBS sessions may be denied; maintenance TMS is not medically necessary

Required Documentation for Prior Authorization

The prior authorization request must include comprehensive documentation to support medical necessity: a psychiatric evaluation, treatment history, standardized outcome measures, and the specific TMS protocol. Insufficient documentation of required prior trials, psychotherapy, or ECT trial/contraindication may result in denial.

• Comprehensive psychiatric evaluation by qualified licensed provider (psychiatrist MD/DO/MBBS or psychiatric nurse practitioner)
• Documentation of the rTMS, iTBS, or dTMS protocol to be used
• Planned use of an evidence‑based standardized depression rating scale (e.g., PHQ‑9) with pre‑treatment score documented and ongoing monitoring during treatment
• Clear documentation if ECT was tried and failed, contraindicated, or why TMS is clinically preferable

Required Prior Trials, Step Therapy & Medication/Augmentation History

Prior to authorization, the member/enrollee must have adequate prior trials and step therapy as follows. Documentation must show failure or intolerance as specified, and a history of medication augmentation attempts when applicable.

• Failure of at least two antidepressant trials from two different classes administered at adequate dose and duration (≥6 weeks) within the last 24 months OR documented inability to tolerate antidepressant trials as specified in policy (e.g., intolerable side effects)
• Documentation of participation in an adequate trial of evidence‑based psychotherapy (e.g., CBT or interpersonal therapy) during the current episode, overlapping with antidepressant trials, without significant improvement
• When applicable, documentation of at least two recognized augmentation treatments attempted (for treatment‑resistant cases) such as lithium, thyroid hormone, second‑generation antipsychotic augmentation, or dual antidepressant approaches
• Medication/augmentation history and prior psychopharmacologic trials must be detailed in the request; insufficient history may result in denial

Evaluation, Referral & Clinical Oversight

Clinical oversight and referral requirements: a comprehensive psychiatric evaluation must be completed and the patient referred for TMS by the provider treating the MDD. Direct supervision of TMS treatment must be provided by a licensed psychiatrist trained in TMS (except where state scope allows otherwise). Medical director review is used for adolescent requests and for authorization of additional/retreatment sessions.

• Referral for TMS by the provider treating the member's MDD
• Comprehensive psychiatric evaluation by a qualified licensed provider completed prior to treatment
• Direct supervision by a licensed psychiatrist trained in TMS, unless state scope permits other supervisors
• Medical director case‑by‑case review for adolescents (15–17) and for retreatment/additional sessions

Protocol & Outcome Measurement Requirements

Protocol and outcome measurement expectations: the TMS provider must document the specific protocol (rTMS, iTBS, or dTMS), device used (FDA‑cleared device), stimulation parameters, and planned outcome measurement using standardized depression rating scales. Scores must be recorded prior to initiation and monitored throughout treatment to support continued authorization.

• Documentation of TMS protocol (rTMS, iTBS, or dTMS) and device (FDA‑cleared) with stimulation parameters
• Planned use of an evidence‑based standardized depression rating scale (e.g., PHQ‑9, PHQ‑A for teens, MADRS) with pre‑TMS score documented
• Ongoing measurement of standardized rating scale scores during course of treatment to document response or lack of response

Evidence Supporting SUD and Comorbidity Exclusions

Evidence note: A randomized clinical trial by Yesavage et al. (2018) in US veterans was used to support exclusions related to treatment in the presence of ongoing substance use disorder, PTSD, and certain comorbidities. Include relevant comorbidity and SUD remission documentation as required.

• Yesavage JA et al., Effect of Repetitive Transcranial Magnetic Stimulation on Treatment‑Resistant Major Depression in US Veterans (JAMA Psychiatry, 2018) supports exclusion considerations for active SUD, PTSD, and comorbidity
• Policy requires documentation of at least three months of substantiated remission from substance use disorder prior to treatment