CurrentOptumPolicy N/A

Repetitive Transcranial Magnetic Stimulation (rTMS) request form

A clinician-facing request form that documents clinical criteria, contraindications, and billing codes for initial, retreatment, and continuation rTMS for Major Depressive Disorder; used by providers submitting authorization requests to the payer.

Policy Summary

PayerOptum

PolicyRepetitive Transcranial Magnetic Stimulation (rTMS) request form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed rTMS request form including clinical criteria, documentation of four adequate pharmacologic trials or other qualifying history, selected CPT code(s), and required pre- and post-treatment rating scale scores.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4min pharmacologic trials

>=50%response threshold

2ICD-10 codes

3CPT codes

Coverage Criteria for rTMS

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Diagnosis: Confirmed diagnosis of severe Major Depressive Disorder (single or recurrent episode) documented with a standardized pre-treatment rating scale (GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, or IDS-SR).

See ICD-10 codes F32.2, F33.2.

Pharmacologic treatment failure, intolerance, prior response, or ECT consideration: One or more of: resistance to psychopharmacologic treatment evidenced by lack of clinically significant response to four adequate trials of at least six weeks; inability to tolerate psychopharmacologic agents documented by trials from at least two different agent classes; history of response to rTMS in a previous depressive episode; currently receiving or considering electroconvulsive therapy (ECT).four adequate trials of ≥6 weeks or trials from at least two different agent classes

Standardized rating scales should document lack of improvement.

Psychotherapy trial: Trial of an evidence-based psychotherapy of adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales (GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, or IDS-SR).

Document frequency/duration and scale scores.

Provider order and supervision: An order written by a psychiatrist (MD or DO) who has examined the patient and reviewed the record; the psychiatrist must have experience administering TMS and will directly supervise treatment.

Retreatment

Retreatment covered when ALL of the following are met:

Prior eligibility and current guideline adherence: Patient met the guidelines for initial treatment previously and currently meets guideline criteria for retreatment.

Relapse: Patient has subsequently developed a relapse of depressive symptoms.

Document relapse with standardized rating scales.

Prior response: Patient previously responded to rTMS with greater than 50% improvement on standard depression rating scales (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, or IDS-SR).>50%

Post-treatment rating scales required to document prior response.

Contraindications include a history of seizure disorder or any history of seizures (with the exception of seizures induced by ECT or isolated febrile seizures in infancy without recurrence), neurological conditions such as epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary/secondary CNS tumors, and prior failed ECT or VNS for Major Depressive Disorder. Also list any implanted magnetic‑sensitive medical devices located ≤30 cm from the TMS coil (for example, cochlear implant, implanted cardiac defibrillator (ICD), pacemaker, vagus nerve stimulation (VNS) device) or other implanted metal items such as aneurysm clips/coils, staples, or stents. Note that dental amalgam fillings are not affected and are acceptable with TMS.

rTMS is inappropriate for patients with active psychotic symptoms or an active psychotic disorder during the current depressive episode (including psychotic disorder or schizoaffective disorder). It is also inappropriate for patients with a diagnosis of bipolar disorder when the current episode includes features that would contraindicate rTMS. Additionally, active seizure disorder or other listed neurological conditions (see contraindications) render patients ineligible; these conditions may lead to a determination of not medically necessary for rTMS.

Diagnoses, Procedure Codes, and Treatment Thresholds

Covered ICD-10 Diagnoses (as listed)ICD-10Covered

F32.2	Major depressive disorder, single episode, severe
F33.2	Major depressive disorder, recurrent episode, severe

TMS CPT CodesCPT

90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment - initial, including cortical mapping, motor threshold determination, and 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 redetermination with delivery and management

inv-07: Minimum adequate pharmacologic trial — four adequate trials of ≥6 weeks or trials from at least two different agent classes

Minimum trials requiredFour adequate pharmacologic trials documented, each of at least six weeks' duration

Alternate demonstrationTrials from at least two different agent classes (documented) may satisfy requirement when intolerance or class-limited trials are present

Documentation standardPrior trials must be documented using standardized depression rating scales (GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, or IDS-SR)

inv-08: Clinical response threshold for prior treatment — >50% improvement on standard rating scales

Response definition>50% improvement on standard depression rating scales (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, or IDS-SR)

Use for retreatmentPrior response meeting this threshold is required to qualify as a responder for retreatment

DocumentationPost-treatment rating scale scores must be provided to demonstrate percent improvement

Provider Requirements and Submission Instructions

Prior Authorization

Prior authorization via request form

Prior authorization is required. Submit the completed rTMS request form including all clinical criteria, selected CPT codes, and required attachments to initiate review.

Include selected CPT codes (e.g., 90867, 90868, 90869) on the request form.
Ensure the FDA‑approved device to be used and the number of sessions are specified.

Step Therapy

Step therapy context

rTMS is generally requested after failure of medication trials and psychotherapy or when medications are not tolerated. Confirm and document prior adequate pharmacologic and psychotherapy trials before submission.

rTMS is typically considered when there is resistance to treatment or intolerance to psychopharmacologic agents.
May be considered as an alternative to ECT when ECT is being considered.

Documentation Required

Required documentation on request form

Complete all required fields on the rTMS request form. Missing or incomplete form fields may result in delayed review or denial.

Member demographics, health plan/policy number, and contact/fax information.
Treating and servicing clinician/facility names, phone, NPI, and TIN.
Pre‑treatment standardized rating scale and score (GDS, PHQ‑9, BDI, HAM‑D, MADRS, QIDS, or IDS‑SR).
Selected treatment type and CPT code(s), FDA‑approved device, and number of sessions requested.

Documentation Required

Clinical history and prior treatment documentation

Document clinical history and prior treatments thoroughly. Lack of adequate documentation of prior trials or durations increases denial risk.

Evidence of a confirmed diagnosis of severe Major Depressive Disorder (F32.2, F33.2) and the pre‑treatment rating scale and score.
Details of four adequate pharmacologic trials in the current depressive episode OR documentation of inability to tolerate pharmacologic agents (include agents, classes, start/stop dates, durations, and reasons for discontinuation).
Documentation of at least one adequate trial of evidence‑based psychotherapy of sufficient frequency and duration and corresponding rating scale results.
If prior rTMS or ECT/VNS was used, provide dates and response details (e.g., >50% improvement on standardized scales for prior response).
For retreatment requests, include dates of initial treatment and evidence of relapse and prior response.

Denial Risk

Contraindication‑based denial risk

Presence of contraindications or certain active conditions may lead to denial. Screen and document contraindications on the request form; if present, provide clinical justification if requesting an exception.

Seizure disorder or any history of seizures (except isolated febrile seizures or ECT‑induced seizures) increases denial risk.
Implanted magnetic‑sensitive devices or metal located ≤30 cm from the TMS coil (e.g., cochlear implant, pacemaker, ICD, VNS, aneurysm clips/stents) increases denial risk.
Active psychosis or acute/chronic psychotic symptoms in the current depressive episode increases denial risk.
Neurological conditions (epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, severe head trauma, CNS tumors) increase denial risk.
Current pregnancy, nursing status, current suicide plan or recent suicide attempt, or other active conditions (e.g., eating disorder) should be documented and may affect approval.

Background

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive neuromodulation therapy indicated for severe Major Depressive Disorder (single or recurrent episodes), typically offered after inadequate response to pharmacologic and psychotherapeutic treatments. Standardized depression rating scales (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, IDS‑SR) are used to document baseline severity and to measure response. Treatments are delivered using an FDA‑approved TMS device under direct psychiatrist supervision, with the specific CPT code(s) and number of sessions specified on the request form.

Definitions and Thresholds

inv-16: Severe Major Depressive Disorder (MDD) — ICD examples F32.2 and F33.2 and reference to standardized rating scales

Example ICD-10 codesF32.2 (Major depressive disorder, single episode, severe) and F33.2 (Major depressive disorder, recurrent episode, severe)

Supporting documentationConfirmed diagnosis must be documented with a standardized pre-treatment rating scale (GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, or IDS-SR)

Clinical contextrTMS indicated for severe MDD single or recurrent episode when criteria for prior treatments and psychotherapy are met

inv-17: Responders for retreatment — defined as >50% improvement on standard depression rating scales

Responder definition>50% improvement on standard depression rating scales (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, or IDS-SR)

Role in retreatmentPrior responders meeting this threshold are eligible for retreatment when relapse occurs and other retreatment criteria are met

Required evidencePost-treatment rating scale scores and dates of initial treatment should be provided to document prior response

Level of Care

Outpatient

Outpatient level of care requirements for rTMS:

Outpatient rTMS admission: Meets diagnostic, prior treatment, psychotherapy, and psychiatric order requirements as listed under Initial Therapy.

Treatment is outpatient-based with direct psychiatrist supervision.

Continued stay or discharge considerations: Ongoing documentation of clinical response via standardized rating scales and psychiatrist oversight to continue sessions; specific continued stay metrics not specified on form.

Maintain supervised outpatient treatment and document response.

Treatment Modalities

TMS

TMS treatment modality and coding:

TMS modality: Use of an FDA‑approved TMS device as specified; therapeutic rTMS services billed with CPT codes 90867 (initial, including cortical mapping and motor threshold determination), 90868 (subsequent delivery and management, per session), or 90869 (subsequent motor threshold redetermination with delivery and management).

Number of sessions to be specified on the request form.

Visit Limits and Session Counts

inv-20: Therapeutic rTMS (CPT 90867/90868/90869) — number of sessions and visit limits for these CPTs

Procedure codes90867 (TMS initial; includes cortical mapping, motor threshold determination, delivery and management)

Subsequent session code90868 (Therapeutic rTMS subsequent delivery and management, per session)

Motor threshold re-determination90869 (Therapeutic rTMS subsequent motor threshold redetermination with delivery and management)

Number of sessionsNumber of sessions must be specified on the request form for the treatment course (listed on form)