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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthOptum TMS Coverage & Prior Auth Update | OpenPayer
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    CurrentOptumPolicy BH803 NYTMS122025

    New York Medicaid and Essential Plan: Transcranial Magnetic Stimulation (TMS) - Medicaid, Child Health Plus and Essential Plan

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    State-specific supplemental clinical criteria governing coverage and medical necessity determinations for TMS for New York Medicaid, Child Health Plus, and Essential Plan members; applies to providers requesting authorization for TMS services under those programs.

    Policy Summary
    PayerOptum
    PolicyTranscranial Magnetic Stimulation (TMS) for Treatment-Resistant Major Depressive Disorder — NY Medicaid, Child Health Plus, Essential Plan
    Policy CodePolicy BH803 NYTMS122025
    Change TypeMaterial updates — added coverage scope, definitions, and provider requirements
    Effective DateNov 1, 2025
    Last ReviewDec 1, 2025
    Next Review DateNov 1, 20269d
    Key ActionObtain prior authorization showing member is ≥18, meets the definition of treatment-resistant MDD (two adequate antidepressant trials), and that a qualified psychiatrist will perform TMS.
    SourceLink
    POLICY UPDATE CHANGES

    Transcranial Magnetic Stimulation is available for NYS Medicaid members 18 years and older diagnosed with treatment-resistant MDD, effective November 1, 2025 for Medicaid and Child Health Plus and November 1, 2026 for Essential Plans.

    Treatment resistance is defined as two trials of a therapeutic dose of two different antidepressants for a sufficient duration without a clinically meaningful response.

    TMS must be performed by a qualified psychiatrist with specialized training and certification.

    Obsessive-compulsive disorder (OCD) is not an indication for NYS Medicaid reimbursement for TMS.

    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.

    18+Minimum age
    2 trialsPrior treatment trials
    90867-90869Procedure codes
    F32.2, F33.2Example diagnosis codes

    Coverage and Medical Necessity Criteria

    inv-01: Coverage Criteria for TMS

    Covered when ALL of the following are met:

    Eligibility and diagnosis: Member is a New York State Medicaid (FFS or MMC), Child Health Plus enrollee, or Essential Plan member (EP effective 11/1/2026) and is age 18 or older with a diagnosis of treatment-resistant major depressive disorder.>= 18 years

    Effective dates: NYS Medicaid/CHP effective 11/1/2025; EP effective 11/1/2026.

    Treatment resistance: Documentation of two trials of a therapeutic dose of two different antidepressants for a sufficient duration without a clinically meaningful response.2 adequate antidepressant trials

    Operational definition of treatment resistance used for authorization determinations.

    Clinical evaluation: Provider confirms diagnosis and rules out other etiologies of depressive symptoms that could interfere with medication effectiveness.

    Required prior to initiation of TMS.

    Treatment setting and provider: TMS must be performed by a qualified psychiatrist with specialized training and certification.

    Provider qualification required for service provision.

    Exclusions: TMS is not indicated for acute suicidality, psychotic depression, primary neurological disorders, or obsessive-compulsive disorder (OCD) (OCD not an indication for NYS Medicaid reimbursement).

    Requests for these indications are not covered under this policy.

    Coverage limitations and exclusions: Transcranial Magnetic Stimulation (TMS) is not indicated for acute suicidality, psychotic depression, or primary neurological disorders. Additionally, obsessive-compulsive disorder (OCD) is explicitly not an indication for New York State Medicaid reimbursement for TMS under this policy.

    TMS is not first-line therapy for depression and, under this policy, the use of TMS as the initial treatment for depressive disorders is not medically necessary. Prior to authorization, members must meet the policy’s defined criteria for treatment-resistant major depressive disorder.

    Procedure and Diagnosis Codes; Member Eligibility

    Applicable CPT CodesCPT
    90867Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management.
    90868Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session.
    90869Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management.
    Example ICD-10 Diagnosis CodesICD-10
    F32.2Major depressive disorder, single episode, severe without psychotic features.
    F33.2Major depressive disorder, recurrent severe without psychotic features.
    Minimum age for TMS coverage
    Minimum member ageMember must be 18 years of age or older (≥ 18)
    Effective date (NY coverage scope)Effective November 1, 2025 for NYS Medicaid and Child Health Plus; Essential Plans effective November 1, 2026
    ApplicabilityApplies to NYS Medicaid fee-for-service, Medicaid Managed Care, and Child Health Plus (and Essential Plans per effective date)

    Authorization, Documentation, and Denial Triggers

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required before initiating TMS. Requests must document the member is 18 years of age or older and meets the policy definition of treatment‑resistant major depressive disorder (see coverage criteria).

    • Applies to NYS Medicaid FFS, MMC, and Child Health Plus (EP plans effective 11/01/2026)
    Step Therapy

    Prior Treatment (Step Therapy)

    TMS is not a first‑line therapy for depression. Prior to authorization, providers must document at least two adequate trials of therapeutic doses of two different antidepressant medications without achieving a clinically meaningful response. Provider documentation should include medication names, doses, start/stop dates, duration, and reason for discontinuation (lack of efficacy or intolerance).

    • Requirement: ≥2 trials of different antidepressants at therapeutic dose and adequate duration
    • TMS contraindicated as first‑line treatment or for acute suicidality, psychotic depression, or primary neurological disorders

    Clinical Background

    Transcranial Magnetic Stimulation (TMS) is a non-invasive brain stimulation therapy used to improve symptoms of major depressive disorder when conventional treatments have failed. Under this policy TMS is indicated for adults with treatment-resistant major depressive disorder who meet the specified prior-treatment, diagnostic, and provider qualifications.

    Operational Definitions

    Treatment-resistant major depressive disorder (MDD) — operational definition
    Operational definitionTreatment-resistant MDD is defined as failure to achieve a clinically meaningful response after two trials of a therapeutic dose of two different antidepressants for a sufficient duration.
    Required documentation of trialsProvide documentation of the two antidepressant trials including agent names, therapeutic doses, and durations on authorization requests.
    Clinical evaluation requirementProvider must confirm diagnosis and rule out other etiologies of depressive symptoms that could interfere with medication effectiveness before initiating TMS.
    Context of useTMS is indicated for treatment-resistant MDD in adults when conventional treatments have failed; it is not first-line therapy.

    TMS Delivery and Modalities

    inv-13: TMS — modality-specific notes

    TMS modality description: Transcranial Magnetic Stimulation is a non-invasive brain stimulation therapy used to improve symptoms of major depressive disorder when conventional treatments have failed.

    Performed by trained, certified psychiatrists for treatment-resistant MDD in adults as specified in coverage criteria.

    Policy Summary
    PayerOptum
    PolicyTranscranial Magnetic Stimulation (TMS) for Treatment-Resistant Major Depressive Disorder — NY Medicaid, Child Health Plus, Essential Plan
    Policy CodePolicy BH803 NYTMS122025
    Change TypeMaterial updates — added coverage scope, definitions, and provider requirements
    Effective DateNov 1, 2025
    Last ReviewDec 1, 2025
    Next Review DateNov 1, 20269d
    Key ActionObtain prior authorization showing member is ≥18, meets the definition of treatment-resistant MDD (two adequate antidepressant trials), and that a qualified psychiatrist will perform TMS.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaProcedure and Diagnosis Codes; Member EligibilityAuthorization, Documentation, and Denial TriggersClinical BackgroundOperational DefinitionsTMS Delivery and Modalities
    Documentation Required

    Documentation Requirements

    Providers must confirm the diagnosis of major depressive disorder and document that other etiologies of depressive symptoms have been ruled out prior to TMS initiation. Include supporting clinical records and documentation of prior treatments (medication trials as above). TMS must be performed by a qualified psychiatrist with specialized training and certification.

    • Documented diagnosis (e.g., F32.2, F33.2 where applicable)
    • Supporting clinical notes that rule out alternate etiologies and justify prior pharmacotherapy trials
    • Proof of treating provider’s TMS training/certification
    Denial Risk

    Triggers for Denial

    Requests may be denied if required criteria are not met. Common denial triggers include: member under 18 years of age; absence of documentation confirming two adequate antidepressant trials; lack of documentation ruling out other causes of depressive symptoms; TMS requested for excluded indications (acute suicidality, psychotic depression, neurological primary disorder, or OCD); or no evidence the provider is qualified to deliver TMS.

    • Member age < 18
    • No documentation of ≥2 adequate antidepressant trials
    • Missing confirmation of MDD diagnosis or lack of documentation ruling out other etiologies
    • Request for TMS for excluded indications (acute suicidality, psychotic depression, primary neurological disorders, OCD)
    • No documentation of provider TMS training/certification