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Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
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Defines when various types of transcranial magnetic stimulation (TMS) are considered medically necessary, investigational, or not medically necessary for treatment of major depressive disorder (unipolar), bipolar depression, obsessive-compulsive disorder, and other conditions; intended for providers and payers.
No material clinical or coverage changes in this revision.
Coverage Criteria for TMS
Initial therapy — Major Depressive Disorder (unipolar)
Covered when ALL of the following are met for Major Depressive Disorder (unipolar):
See Additional Information
Initial therapy — Bipolar depression
Covered when ALL of the following are met for Major Depression as a component of Bipolar Disorder (bipolar depression):
No psychotic or manic features
Theta burst is considered investigational for bipolar depression
Initial therapy — Obsessive-Compulsive Disorder
Covered when ALL of the following are met for Obsessive-Compulsive Disorder (OCD):
Theta burst considered investigational for OCD
Course length, extensions, accelerated, maintenance
Coverage rules for course length, extensions, accelerated and continuation/maintenance:
First session may include planning/mapping/threshold determination; 1–3 subsequent sessions may include re‑determination
Motor threshold re‑determination limits apply
Deep TMS SWIFT described separately
Maintenance not covered if preceding intensive course was found not medically necessary
Repeat and booster courses
Repeat and short/brief intensive courses:
A second full intensive failure indicates TMS not effective
Not covered if symptoms mild/not worsening
Short/Brief Intensive Course — Initial/Repeat
Short or brief intensive TMS course — Covered when ALL of the following are met
Short/brief course not medically necessary if symptoms mild/not worsening or prior course was not medically necessary
Concurrent TMS and VNS (conditional coverage)
TMS in conjunction with other neuromodulation or devices
Applies while awaiting VNS effectiveness
Not Medically Necessary / Investigational
Not Medically Necessary or Investigational scenarios
These uses are explicitly disallowed or investigational in the policy
TMS + VNS (time-limited medically necessary)
Covered when ALL of the following are met (time-limited allowances):
Individual must have just completed a full or brief intensive TMS course and be transitioning to or undergoing maintenance TMS and prior TMS was partially but inadequately effective.
Conditional based on reassessment at each interval completion.
Investigational / Not Medically Necessary
Not covered or considered investigational when ANY of the following apply:
Denial likely for concurrent use regardless of indication.
May lead to denial of services.
Concurrent use coverage rules
Coverage stance for concurrent TMS use with other modalities:
Each extension requires documented lack of improvement.
Adjunctive TMS coverage criteria
Coverage stance for TMS when combined with other treatments:
Investigational — not covered
Initial allowable interval
Requires documented lack of VNS effectiveness at each interval.
Stop criterion
TMS with VNS — initial and extension criteria
Use of TMS in conjunction with VNS — covered when ALL of the following are met:
Individual must have just completed a full or brief intensive TMS course and be transitioning to or undergoing maintenance TMS and prior TMS must have been partially but inadequately effective.
Reassessment required at each interval end.
TMS with VNS — not medically necessary
Either condition makes continued overlap not medically necessary.
TMS with Spravato/ketamine/psychedelics — investigational
Concomitant use is not supported by this policy.
TMS in conjunction with VNS (Major Depressive Disorder)
Covered when ALL of the following are met for TMS in conjunction with VNS:
See extension rules.
Requires standardized rating scale assessment at each interval completion.
Either condition suffices to stop coverage.
Investigational: Spravato/ketamine/other psychedelics
Investigational — not covered per these chunks.
TMS used in conjunction with VNS (time-limited coverage)
Covered when the following conditions are met for concurrent use of TMS with VNS:
All conditions must be met
Duration and discontinuation criteria
Limits and continuation logic for concurrent TMS+VNS:
Either condition ends coverage
Investigational combinations (TMS + psychedelics)
Not covered / investigational:
Not covered per policy
Medically necessary combined TMS and VNS
Use of TMS in conjunction with VNS may be considered medically necessary under the following conditions:
All conditions must be met for combined therapy to be medically necessary
TMS in conjunction with VNS — Medically Necessary Conditions
Covered when ALL of the following are met:
Documentation required
Each interval requires documentation of lack of improvement.
These are end points for coverage.
Initial combined-use medical necessity
Use of TMS in conjunction with VNS may be considered medically necessary when ALL of the following apply:
Supported across policy text
Extension criteria
Extensions may be considered when ALL of the following are met:
Each interval requires demonstration that VNS has not achieved improvement
Not medically necessary — continued combined therapy
Combined therapy is considered not medically necessary when ANY of the following occur:
Either condition makes continued TMS+VNS not medically necessary
Medically Necessary Concurrent TMS and VNS
Covered when ALL of the following are met
Requires prior completion of a full or brief intensive TMS course and that TMS was partially but inadequately effective.
Assessment required at each interval
Medically necessary, time-limited concurrent TMS with VNS
TMS used in conjunction with VNS for Major Depressive Disorder is considered medically necessary only under the following time-limited conditions:
Applies when individual completed an intensive TMS course and prior TMS was partially but inadequately effective.
Continuation requires documented lack of improvement after each interval.
Either condition ends coverage.
Medically necessary: TMS in conjunction with VNS (limited)
TMS used in conjunction with VNS may be considered medically necessary when ALL of the following are met:
Each interval requires standardized rating scale assessment.
Not medically necessary: TMS in conjunction with VNS (disallowed uses and stop conditions)
TMS in conjunction with VNS is considered not medically necessary when ANY of the following are met:
Continued TMS is not covered once this is met.
After 12 months concomitant TMS is not medically necessary regardless of symptom status.
Limited concurrent TMS with VNS — medically necessary conditions
Covered when ALL of the following are met (limited concurrent use of TMS with VNS):
These are the limited scenarios where TMS with VNS may be considered medically necessary.
Applies when waiting for VNS effect.
Each extension requires standardized rating scale assessment before further extension.
Either condition stops coverage.
All TMS modalities and protocols not explicitly listed as covered in this policy are considered investigational and excluded from medical necessity coverage. Examples include imaging-guided or neuronavigation-guided TMS, computer-assisted TMS, MeRT, MRI-/EEG-guided TMS, low-field magnetic stimulation, magnetic seizure therapy, multiarray or navigated TMS, single-pulse or synchronized TMS, and the SNT/SAINT protocol.
Consecutive or overlapping courses of TMS intended to treat different conditions (for example, a course for Major Depressive Disorder followed immediately by a course for Obsessive-Compulsive Disorder) are considered not medically necessary and are excluded from coverage.
Consecutive or overlapping TMS courses for different indications are explicitly not medically necessary; sequencing separate courses without meeting the policy’s timing and clinical criteria is disallowed.
Administration of TMS by more than one provider, group, or clinic concurrently (overlapping treatment sessions delivered by different providers at the same time) is considered not medically necessary and may result in claim denial.
Use of TMS in conjunction with Spravato (esketamine), any form of ketamine, or any other psychedelic drug is classified as investigational and is not eligible for medically necessary coverage when administered concurrently.
TMS provided concurrently by more than one provider/group/clinic at the same time is explicitly labeled not medically necessary and may be denied.
Requests to provide TMS together with Spravato, ketamine, or any other psychedelic agent are considered investigational and are excluded from medical necessity coverage.
Concurrent delivery of TMS by multiple providers/groups/clinics is considered not medically necessary and is an explicit exclusion in the policy.
The policy reiterates that TMS administered together with Spravato, ketamine, or other psychedelic drugs is investigational and therefore not covered.
Use of TMS in combination with psychedelic drugs (including Spravato and ketamine) is considered investigational and excluded from coverage.
Continued concurrent TMS provided while a patient is receiving VNS is not medically necessary once depression has improved to mild or remission on a standardized rating scale; at that point additional overlap is excluded.
The policy restates that combining TMS with psychedelic agents such as Spravato or ketamine is considered investigational regardless of indication and is not supported.
TMS delivered in conjunction with vagus nerve stimulation (VNS) may be considered medically necessary only in narrowly defined situations: specifically, as a time-limited bridge while awaiting VNS effectiveness when the individual has just completed a full or brief intensive TMS course and is transitioning to or undergoing maintenance TMS and prior TMS response was partially but inadequately effective.
The policy allows TMS with VNS only as a temporary measure when transitioning to VNS or waiting for VNS to become effective; this combined use is limited by the specified time intervals and clinical criteria.
Restatement: concurrent TMS with an implanted VNS device is not routinely medically necessary and is permitted only under the policy’s transition/awaiting-effectiveness rules.
Again, TMS may be continued short-term when transitioning to VNS only when the individual has completed a recent intensive TMS course, is moving to maintenance TMS, and prior TMS benefit was partial but inadequate; otherwise concurrent use is not supported.
TMS provided concurrently during the VNS peri-implant period is limited and allowed only for defined transition/awaiting-effectiveness scenarios; outside those scenarios combined therapy is not medically necessary.
Any other use of TMS together with a vagus nerve stimulator for psychiatric conditions beyond the limited, specified scenarios is considered not medically necessary and excluded from coverage.
Restatement: concurrent TMS with VNS is only permitted in the narrow transition/maintenance situations described; other combined uses are not medically necessary.
The presence of contraindications will make TMS not medically necessary and may trigger denial; examples include a brain tumor without neurologist/neurosurgeon clearance, non-removable ferromagnetic implants in the head/neck within 30 cm of coil placement, unstable or uncontrolled seizure disorder (unless stable and well-controlled), active psychosis, ongoing substance abuse, or lack of required medical clearance.
Motor threshold re-determination is limited: more than three treatment sessions that include motor threshold re-determination are considered not medically necessary except in specific circumstances (e.g., equipment problems, suspected incorrect mapping, medical changes affecting cortical excitability, clinical events that lower seizure threshold, or planned parameter changes with justification).
A short or brief intensive course is considered not medically necessary if depression or OCD symptoms are in remission or mild and not worsening; short/brief courses are intended for documented clinical worsening and are limited in total treatments based on severity.
Consecutive or overlapping TMS courses for different conditions are explicitly considered not medically necessary and are excluded.
TMS administered by more than one provider/group/clinic at the same time is considered not medically necessary and may be denied.
Use of TMS together with Spravato, ketamine, or any other psychedelic drug remains classified as investigational and is not eligible for coverage under this policy.
Concurrent administration of TMS by multiple providers at the same time may be denied as not medically necessary; requests for payment in that circumstance are at risk of denial.
Continued TMS provided concurrently with VNS is not medically necessary when the individual's depression has improved to mild or remission on a standardized rating scale; this is a clear discontinuation criterion.
Restatement: ongoing concurrent TMS with VNS must stop when standardized rating scales show improvement to mild or remission; otherwise continued overlap is not supported.
The policy reiterates that combining TMS with Spravato, ketamine, or other psychedelic drugs is investigational and would be excluded from medical necessity coverage.
Restatement: continued concurrent TMS with VNS is not supported once depression reaches mild or remission per standardized assessment; this remains a trigger for discontinuation/denial.
Reiteration: continued combined TMS and VNS is not medically necessary when standardized scales indicate improvement to mild or remission.
Use of TMS together with psychedelic drugs (Spravato, ketamine, others) is investigational and therefore not considered medically necessary in the policy's scope.
Again: continued concurrent TMS with VNS should be discontinued when depression improves to mild or remission on a standardized rating scale; coverage ceases at that clinical threshold.
Use of TMS in conjunction with other neuromodulation modalities beyond the specified VNS timing and conditions is considered investigational and is not supported for coverage.
Restated: concurrent TMS with VNS becomes not medically necessary when standardized measures show improvement to mild or remission, and at that point continuation should be denied.
Again reiterated: the policy does not support continued TMS with VNS once standardized assessments indicate improvement to mild or remission.
Repeated statement: continued concurrent TMS and VNS is not medically necessary if the patient attains mild symptom level or remission by standardized rating scale.
Policy reiteration: when standardized measures show improvement to mild or remission, continued combined TMS+VNS is not supported as medically necessary.
Restating the stop rule: achievement of mild severity or remission on a standardized rating scale ends the medical necessity for concurrent TMS with VNS.
Coding and Treatment Counts
| Not listed in this extract | Procedure CPT/HCPCS codes referenced in 'CODING RELATED INFORMATION' are not present in this document portion |
Prior Authorization, Documentation, and Denial Triggers
Obtain prior authorization for maintenance and repeat full courses
Prior authorization is required for initiation and continuation of maintenance TMS and for repeat full intensive courses; initial authorization periods and reauthorization limits are specified (e.g., maintenance initial up to 16 weeks at 2/week, up to 26 weeks at ≤1/week).
Prior authorization required for short/brief intensive and maintenance courses
Obtain prior authorization when requesting short/brief intensive (booster) or maintenance TMS courses; requests must meet the medical necessity criteria (e.g., prior response and documented worsening, timing and treatment-count limits).
Seek authorization for TMS used with VNS beyond standard intervals
Prior authorization may be required when TMS is used concurrently with VNS beyond usual coverage; concurrent TMS+VNS is only considered medically necessary for defined, time-limited intervals and requires documentation of the clinical context.
Authorize each extension when continuing TMS with VNS
Prior authorization may be required to continue TMS concurrently with VNS beyond the initial 3‑month post-implant period and for each additional 3‑month interval if VNS has not produced improvement.
Prior authorization for the initial TMS+VNS overlap interval
Obtain prior authorization when planning TMS during the VNS implantation/overlap period; documentation must show recent completion of an intensive TMS course and partial but inadequate response to TMS as the rationale.
Provide authorization to continue TMS after initial 3 months post‑VNS
Prior authorization is implied for continuation of TMS used with VNS beyond the initial 3‑month post‑implantation period and for any subsequent additional 3‑month intervals; provide evidence that VNS has not resulted in improvement to mild or remission.
Document authorization periods for TMS with VNS
Prior authorization requests should reflect that TMS in conjunction with VNS may be authorized for an initial 3‑month period after implantation and for up to three additional 3‑month intervals if VNS has not produced improvement to mild or remission.
Implied authorization for defined concurrent TMS+VNS intervals
Prior authorization is implied when requesting time‑limited concurrent TMS+VNS while awaiting VNS effectiveness; include documentation of prior intensive TMS completion and partial but inadequate effectiveness.
Obtain authorization tied to allowed intervals and outcome thresholds
Prior authorization is implied for continuation of TMS with VNS beyond initial implantation periods; TMS may be authorized up to 3 months post‑implant and up to three additional 3‑month intervals only if VNS has not produced improvement to mild or remission on a standardized rating scale.
Authorization required and limited for concurrent TMS+VNS
Prior authorization is required to continue TMS in conjunction with VNS beyond VNS implantation; coverage is limited to an initial 3‑month period and up to three additional 3‑month intervals if no improvement is documented on standardized rating scales.
Include implantation timing and outcome documentation in prior‑auth requests
When requesting authorization for TMS with VNS outside stated medically necessary intervals, provide documentation of VNS implantation date, prior TMS course completion, maintenance status, and standardized rating scale outcomes.
Time‑limited approvals require evidence VNS is ineffective
Prior authorization is implied for continued concurrent TMS with VNS beyond implantation; approvals are time‑limited and contingent on documented lack of VNS effectiveness per standardized scales at interval completions.
Authorize concurrent TMS during each permitted 3‑month block
Prior authorization is required for TMS continued in conjunction with VNS when treatment occurs within the initial 3‑month post‑VNS interval or any of up to three additional 3‑month intervals if VNS has not produced improvement.
Authorize extensions only with standardized scale evidence
Prior authorization is implied for continued TMS used with VNS beyond initial post‑implant management; coverage is limited to an initial 3‑month period and may be extended up to three additional 3‑month intervals only if standardized rating scales show lack of improvement.
Authorization required for extended concurrent TMS+VNS
Prior authorization is required to continue TMS with VNS beyond transition/maintenance situations; use remains limited to specific 3‑month intervals and clinical thresholds described in the policy.
Provide prior medication trial documentation
Document failure of prior medication trials for MDD/bipolar depression: for MDD, failure of ≥3 antidepressants from ≥2 classes OR ≥2 antidepressants from ≥2 classes plus augmentation; for bipolar depression, failure of ≥3 specified bipolar agents is required.
Meet medication‑trial prerequisites before TMS
Policy requires demonstration of prior medication trial failure per indication as a step before TMS (e.g., ≥3 antidepressants from ≥2 classes or specified bipolar medication failures).
Step therapy sequences not further specified
No explicit multi‑step therapy sequence beyond medication trial prerequisites is specified in these excerpts.
Allow short‑term TMS while awaiting VNS effectiveness
TMS may be used temporarily while awaiting VNS effectiveness if the patient completed a full or brief intensive TMS course, is transitioning to or undergoing maintenance TMS, and TMS was partially but inadequately effective.
Note on step therapy for combined use
No additional explicit step therapy requirements are stated beyond the need for TMS to have been 'partially but inadequately effective' prior to continued/maintenance use with VNS.
Require prior intensive TMS before continuing during transition to VNS
TMS may be continued short‑term when transitioning to VNS only after completion of a full or brief intensive TMS course and if TMS was partially but inadequately effective.
Require prior intensive TMS before combined therapy
Combined TMS+VNS is allowed only when the individual has completed an intensive TMS course and is transitioning to or undergoing maintenance TMS and prior TMS was partially but inadequately effective.
Allow bridge neuromodulation for initial 3 months post‑VNS
Other neuromodulation modalities may be considered for up to 3 months after VNS implantation while awaiting VNS effect if the individual has just completed a full or brief intensive TMS course and is transitioning to maintenance TMS or is undergoing maintenance TMS and prior TMS was partially but inadequately effective.
Expect prior TMS course and transition to maintenance when bridging to VNS
Policy expects a prior course of TMS (full or brief intensive) and transition to maintenance TMS when TMS is used during the VNS effectiveness waiting period; document prior partial/inadequate response.
Document TMS technical procedures and justify re‑determinations
TMS technical documentation must include treatment planning and cortical mapping, initial motor threshold determination, and motor threshold re‑determination sessions; frequency limits on re‑determination require justification.
Document symptom worsening to justify repeat/booster courses
Record worsening of depression or OCD with clinical notes or a standardized rating scale when repeating a course of TMS after prior positive response or for maintenance/booster courses.
Support TMS+VNS requests with timing and prior‑course documentation
For concurrent TMS with VNS, documentation must support that use is within the allowed timeframe and meets conditions (recent completion of a full/brief intensive TMS course and partial but inadequate TMS effect).
Provide standardized‑scale evidence for each extension interval
When extending concurrent TMS with VNS beyond the initial 3 months, provide documentation demonstrating that VNS has not resulted in improvement to mild or remission on a standardized rating scale at the completion of each interval.
Declare concomitant psychedelic use and VNS timing in documentation
Documentation should state whether TMS is being used concurrently with Spravato, ketamine, or other psychedelic drugs or during the post‑VNS implantation period, and include prior TMS response and VNS effectiveness assessed with standardized scales.
Submit standardized rating scale outcomes
Include standardized rating scale results in documentation to demonstrate whether depression has improved to mild or remission to support continuation or discontinuation decisions for TMS with VNS.
Include scale scores and VNS implantation dates
Provide standardized rating scale scores showing whether depression has improved to mild or remission at interval completions and include dates of VNS implantation to determine elapsed time for coverage decisions.
Use standardized rating scales to justify continuation or stopping
Evaluation of improvement must use a standardized rating scale to justify discontinuation of concurrent TMS with VNS or to determine continued medical necessity.
Provide baseline and interval standardized assessments and dates
Documentation should show baseline and interval standardized rating scale scores, dates of VNS implantation, and whether the patient completed a full or brief intensive TMS course and is transitioning to or undergoing maintenance TMS.
Document prior intensive course and current maintenance status
When requesting concurrent TMS+VNS, demonstrate recent completion of a full or brief intensive TMS course and that the patient is transitioning to or receiving maintenance TMS, including standardized rating scale scores documenting lack of improvement to mild or remission.
Use interval scale results to support continuation decisions
Provide standardized rating scale results at each interval completion to demonstrate whether depression has improved to mild or remission and to determine if continuation is allowed.
Include timing, prior course completion, and partial response evidence
Documentation should demonstrate timing of VNS implantation, completion of a full or brief intensive TMS course, transition to maintenance TMS (if applicable), and that TMS was partially but inadequately effective, with standardized rating scale scores.
Provide comprehensive documentation for interval counts and 12‑month limit
Recommended documentation to support medical necessity includes timing of VNS implantation, completion of a full or brief intensive TMS course and transition to maintenance TMS, standardized rating scale scores showing depression remains worse than mild, and dates supporting count of 3‑month intervals and the 12‑month implant anniversary.
Include implantation date plus scale scores to determine medical necessity
Documentation of standardized rating scale scores demonstrating level of depression (e.g., to show improvement to mild or remission) and VNS implantation date is necessary to determine continued medical necessity for concurrent TMS and VNS.
Contraindications must be cleared or risk denial
Presence of contraindications — e.g., brain tumor without neurologist/neurosurgeon clearance; non‑removable ferromagnetic implants in head/neck within 30 cm; uncontrolled seizure disorder — will render TMS not medically necessary and may trigger denial.
Repeat full intensive course denied if prior course was non‑covered
A repeat full intensive course is considered not medically necessary and may be denied if the preceding course was determined not medically necessary by the Company.
Avoid concurrent/overlapping courses or multiple providers
Concurrent or overlapping TMS courses for different conditions, or TMS delivered by more than one provider/group/clinic at the same time, are considered not medically necessary and may trigger denial.
Do not combine TMS with Spravato/ketamine/psychedelics
Use of TMS in conjunction with Spravato (esketamine), any type of ketamine, or any other psychedelic drug is considered investigational and may be denied.
Concurrent multiple‑provider TMS risks denial
TMS provided concurrently by more than one provider/group/clinic at the same time is explicitly considered not medically necessary and may be denied; requests for payment in that scenario may be denied.
Investigational combinations with psychedelics will be denied
Requests for TMS provided in conjunction with Spravato, any form of ketamine, or any other psychedelic drug are considered investigational and may be denied.
Continuation beyond improvement or 12 months risks denial
Continued TMS in conjunction with VNS is considered not medically necessary when depression has improved to mild or remission on a standardized rating scale, or when 12 months have elapsed since VNS implantation; such continued use is at risk for denial.
TMS plus psychedelics considered investigational — denial likely
Use of TMS in conjunction with Spravato, ketamine, or any other psychedelic drug is investigational and may be denied.
Stop concurrent TMS when improvement or 12‑month limit reached
Repeatedly, continued TMS with VNS is not medically necessary once depression improves to mild or remission by standardized rating scale or after 12 months post‑implant; providers should anticipate denial if these conditions are met.
Denial triggers: improvement to mild/remission or 12‑month elapsed
Continued concurrent TMS+VNS is not medically necessary and may be denied when either depression has improved to mild or remission on a standardized rating scale or 12 months have elapsed since implantation.
Provide interval assessments to avoid denial when possible
Continued TMS in conjunction with VNS is considered not medically necessary (and at risk for denial) when depression has improved to mild or remission on a standardized rating scale, or when 12 months have elapsed since VNS implantation.
Do not continue combined therapy after improvement or 12 months
Continued combined therapy is considered not medically necessary when either depression has improved to mild or remission on a standardized rating scale or when 12 months have elapsed since vagus nerve stimulator implantation; authorization beyond those points is not supported.
Expect denials for continued concurrent TMS beyond policy limits
Continued TMS in conjunction with VNS is not medically necessary when either depression has improved to mild or remission by standardized rating scale or when 12 months have elapsed since implantation; such uses are subject to denial.
Cease concurrent TMS at clinical or time-based stop points
Repeatedly ensure that continued concurrent TMS is halted once either standardized rating scales show improvement to mild/remission or the 12‑month post‑implant limit is reached to avoid denial.
Denial risk when improvement or 12‑month threshold met
Continued TMS in conjunction with VNS is considered not medically necessary and may be denied when depression has improved to mild or remission on a standardized rating scale, or 12 months have elapsed since VNS implantation.
Provide interval evidence to avoid denials for concurrent TMS
Continued TMS in conjunction with VNS is considered not medically necessary (and therefore at risk for denial) when either depression has improved to mild or remission on standardized scales or when 12 months have elapsed since implantation.
Submit core clinical documentation with prior‑auth
Required documentation must show the individual's age, current episode severity (clinical notes or standardized depression/OCD rating scale), prior medication trials (number, classes, and augmenting agents), and any required specialist evaluation (e.g., neurologist/neurosurgeon clearance for brain tumor/head lesion/TBI or implanted devices).
Include TMS technical records and justify re‑determinations
Document treatment planning/cortical mapping and motor threshold determinations; justify frequency of motor threshold re‑determination as policy limits re‑determination frequency unless specific conditions apply.
Show documented symptom worsening for repeat/booster courses
When repeating a course after prior positive response or during maintenance, provide documentation demonstrating worsening of depression or OCD symptoms via clinical notes or a standardized rating scale.
Document allowed clinical context for TMS+VNS
For concurrent TMS with VNS, include documentation that concurrent use is within allowed timeframe (initial 3 months post‑implant) and meets conditions (recent completion of intensive course, transition to maintenance, partial but inadequate TMS effect).
Submit interval‑end standardized scale evidence for extensions
When requesting extensions beyond the initial 3‑month interval for TMS with VNS, provide standardized rating scale evidence at the end of each interval showing that VNS has not produced improvement to mild or remission.
Declare any concurrent psychedelic therapy (investigational)
Documentation should state whether TMS is being used with Spravato, ketamine, or other psychedelic drugs; such combinations are investigational and documentation will not make them eligible for authorization.
Provide standardized scale results to justify continuation
Include standardized rating scale results demonstrating whether depression has improved to mild or remission to support continuation decisions for TMS with VNS.
Document scores and dates to support continuation or discontinuation
Documentation to support continuation decisions should include standardized rating scale scores at interval completions and dates of VNS implantation to determine elapsed time against policy limits.
Definitions and Background
Transcranial magnetic stimulation (TMS) uses an electromagnetic coil placed on the scalp to generate magnetic fields that induce weak electrical currents in targeted brain regions involved in mood regulation. The policy differentiates commonly used modalities (deep TMS, standard/conventional repetitive TMS, theta burst stimulation, and certain accelerated protocols) from investigational variants and outlines when TMS may be considered medically necessary for depressive and obsessive-compulsive disorders.
Permitted and Investigational Treatment Modalities
Treatment Frequency, Course Limits, and Maintenance
Background
TMS is a noninvasive neuromodulation technique in which a coil placed on the scalp produces magnetic pulses that induce electrical currents in cortical regions; this policy describes covered modalities and clinical contexts for medically necessary use versus investigational approaches.
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