Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Defines when various types of TMS (deep TMS, standard repetitive TMS, theta burst with exceptions) are considered medically necessary or investigational for major depressive disorder, bipolar depression, and obsessive-compulsive disorder, and describes course types, extensions, maintenance, and contraindications for members of Premera Blue Cross.
Policy Summary
PayerPremera Bluecross
PolicyTranscranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Policy CodePolicy 2.01.50
Change TypeMaterial updates to coverage criteria and operational CPT code relocation
Effective DateOct 1, 2025
Next Review DateN/A
Key ActionInclude prior authorization with documentation of diagnosis, standardized severity rating, and prior medication trials when requesting TMS.
Moved CPT codes 0889T-0892T to this policy from policy 10.01.533 to match criteria.
Added a criterion for resumption of maintenance TMS treatment when previous maintenance TMS treatment had been stopped.
Modified contraindications related to brain tumor and repetitive or severe head trauma to require neurologist or neurosurgeon evaluation documenting safety for TMS.
Theta burst stimulation added as medically necessary for Major Depressive Disorder when criteria are met; adolescents 15+ added as eligible when criteria are met; medication trial requirements for MDD reduced from four to three.
Clarified that maintenance TMS or repeat courses are not medically necessary if preceding course was determined not medically necessary.
3Medically necessary TMS types
15-36
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Full course treatments (typical)
<=2/wkMaintenance frequency
50%Clinical response threshold
0889T-0892TMoved CPT codes
Coverage Criteria and Medical Necessity
Initial therapy eligibility (general)
Covered when ALL of the following are met for each indication
TMS type eligibility: Type must be deep transcranial magnetic stimulation, standard/conventional repetitive transcranial magnetic stimulation, or theta burst stimulation (excluding accelerated theta burst and the SNT/SAINT protocol).
See investigational list for excluded/experimental types
Indications: Major Depressive Disorder (unipolar), Major depression as a component of Bipolar Disorder (bipolar depression), or Obsessive-Compulsive Disorder (OCD).
Specific age and prior treatment criteria apply per indication
Major Depressive Disorder (unipolar)
Major Depressive Disorder (unipolar depression) — Covered when ALL of the following are met
Age: Individual is aged 15 years or older.
Severity documentation: Current episode of moderate to severe depression documented by the individual's symptoms and severity or by one or more standardized depression rating scales.
See Additional Information for required documentation
Prior treatment failure: Either failure of at least 3 antidepressant medications from at least 2 different classes OR failure of at least 2 different antidepressant medications from at least 2 different classes plus failure with the addition of an augmenting agent to at least one of the failed antidepressants.
Each failed medication must be identified with reason; minimum 30 continuous days at therapeutic dose unless stopped for intolerable adverse effects.
Major depression as a component of Bipolar Disorder (bipolar depression)
Bipolar depression — Covered when ALL of the following are met
Age: Individual is aged 18 years or older.
Severity documentation: Current episode of moderate to severe depression documented by the individual's symptoms and severity or by a standardized rating scale; without psychotic or manic features.
Medication failures: Failure of at least 3 bipolar-appropriate medications (examples include cariprazine, lamotrigine, lithium, lumateperone, lurasidone, olanzapine–fluoxetine combination, quetiapine, valproate).
Each failed medication must be documented with reason and duration per policy requirements.
Obsessive-Compulsive Disorder (OCD)
Obsessive-Compulsive Disorder — Covered when ALL of the following are met
Age: Individual is aged 18 years or older.
Severity documentation: OCD is currently moderate to severe as demonstrated by documentation of the individual's symptoms and their severity or by a standardized rating scale (extreme scores considered equivalent to severe).
Diagnosis code severity descriptor alone is insufficient; require symptom documentation or rating scale score.
Medication failures: Failure of at least 3 medications including clomipramine or multiple SSRIs, with each failed medication identified and reason for failure documented.
Minimum duration and dosing rules apply per policy (see Additional Information).
Full intensive course definitions
Full intensive course dosing and duration
Standard/conventional full course: 30 treatments over 6–7 weeks at one treatment daily (4–5 days/week); optional 6‑treatment taper over 3 weeks (total 30 or 36 treatments).30 or 36 treatments
First session may include planning/cortical mapping and initial motor threshold determination; 1–3 subsequent sessions may include motor threshold re‑determination.
Deep TMS full course: Either 20 treatments over 4 weeks (intensive phase) followed by 2 treatments weekly for 10–12 weeks (continuation) for a total of 40–44 treatments, OR 30 treatments over 6–7 weeks with optional 6‑treatment taper for total 30 or 36 treatments.40–44 or 30/36 treatments
First session may include planning/cortical mapping and initial motor threshold determination; 1–3 subsequent sessions may include motor threshold re‑determination.
Extended intensive course
Extensions of intensive course — Covered when ALL of the following are met
Clinical response criteria: Extension allowed when minimal or no improvement, slow response with persistent moderate/severe symptoms, partial response with persistent moderate/severe symptoms, symptom worsening during taper, or to obtain additional symptom reduction toward remission.
Document symptom severity or standardized rating scale to justify extension.
Extension dosing limits: Extension consists of one treatment daily (4–5 days/week) with maximum total of 10 treatments if symptoms are mild, 15 if moderate, or 20 if severe; motor threshold re‑determination allowed per severity (1 session for mild/moderate, 1–2 for severe).max 10/15/20 treatments
Additional extensions possible if improvement noted; extensions not medically necessary if no improvement or worsening.
Accelerated, short intensive, and maintenance TMS
Accelerated, short/brief intensive, and maintenance courses
Accelerated intensive TMS: Up to 2 TMS treatments daily (no change in total number of treatments) may be considered medically necessary for individuals with significant travel hardship or other legitimate barriers; more than 2 treatments/day is not medically necessary.2/day maximum
Exceptions limited to documented hardship scenarios.
Short/brief intensive (booster) course: May be considered medically necessary for individuals with positive prior response and recurrence or during maintenance worsening; not allowed if prior course was deemed not medically necessary. Course consists of one treatment daily (4–5 days/week) with maximum treatments per severity (10 mild / 15 moderate / 20 severe) and must not have had a booster within the prior 90 days.max 10/15/20 treatments; no booster within 90 days
Motor threshold redetermination allowances per severity; not medically necessary if symptoms are mild/not worsening or prior course was non-covered.
Conditions for repeat full intensive course
Repeat full intensive course — Covered when ALL of the following are met
Repeat course after prior positive response: Individual had a prior positive response, symptoms have worsened to moderate or severe, and the last TMS treatment was at least 90 days ago.>=90 days since last TMS
Only one repeat full intensive course considered medically necessary when prior course failed; failing after second full course indicates TMS is not effective.
Repeat course after failed TMS: If the individual failed to respond adequately to a current course of TMS, a new full course with a different TMS type or coil placement may be considered medically necessary; only one repeat full intensive course is allowed when a course failed.
Repeat not medically necessary if symptoms are mild/remission or prior course was determined not medically necessary by the Company.
Medical necessity and coverage criteria
Covered when ALL of the following are met for the specified course type
General: Individual has a qualifying diagnosis (MDD, bipolar depression, or OCD) with documentation of symptom severity by narrative or standardized rating scale; required medication trials documented as failed per policy; age and absence of contraindications or documentation of specialist clearance when indicated.see documentation requirements
See Additional Information and Documentation modules for specifics on medication trial duration and severity documentation.
Full intensive course recurrences: A repeat full intensive course is not medically necessary if the preceding full intensive course was determined by the Company to be not medically necessary; if preceding course was under a non‑Company plan, documentation that prior medical necessity criteria were met is required.N/A
Consecutive/overlap rules apply.
Short/brief (booster) intensive course criteria:
Evidence-based coverage considerations
Findings relevant to coverage decisions (evidence-based criteria described in trials):
Acute rTMS candidacy: Individuals with major depressive disorder meeting TRD study definitions (commonly failure of ≥1, often ≥2, adequate antidepressant trials in the current episode), documented baseline severity on HAM‑D or MADRS, are candidates for high‑frequency left DLPFC rTMS or alternatives based on trial evidence.prior treatment failures >=1 (often >=2)
Multiple RCTs and meta‑analyses show benefit versus sham for severity, response, and remission; larger trials required for some modalities.
rTMS modality and targeting: High‑frequency left DLPFC, low‑frequency right DLPFC, bilateral, and deep TMS were studied; device, targeting (including MRI‑guided), and intensity differences may affect outcomes.modalities as per trials
Targeting and protocol details influenced response in several trials.
Comparative effectiveness vs ECT:
Coverage summary: Not routinely covered / investigational for most non-depression indications
Summary conclusions for non-depressive indications
General investigational conclusion: For psychiatric and neurologic conditions other than Major Depressive Disorder (and the FDA‑cleared migraine indication), available randomized trials are small, heterogeneous, and provide mixed results; rTMS is considered investigational for these other conditions.
No large, high‑quality replicated trials identified.
Conditions with some positive but limited evidence: Certain conditions show preliminary or modest benefits in small trials or meta‑analyses (examples: PTSD, OCD augmentation, Parkinson disease motor scores, temporoparietal TMS for auditory hallucinations), but durability and larger confirmatory trials are lacking.
Further study required before routine coverage.
Migraine and FDA‑cleared device note: A pivotal RCT of an external single‑pulse TMS device (Cerena) showed benefit in a post‑hoc subset for migraine with aura but had high dropout and limitations; FDA labeling does not support efficacy for cluster or chronic migraine or for associated migraine symptoms.
Coverage and investigational determinations
Coverage/medical necessity stance derived from evidence and guideline synthesis in this section:
Medicare‑aligned left prefrontal rTMS coverage: Left prefrontal rTMS is covered per Medicare NCD/LCDs for patients diagnosed with severe Major Depressive Disorder (single or recurrent) meeting DSM‑5 criteria and additional coverage requirements.
See Documentation and Prior Authorization modules for payer‑specific requirements.
TMS as option in TRD: TMS is supported as an appropriate intervention in treatment‑resistant unipolar depression after multiple failed antidepressant trials and where ECT is undesirable or has failed; guideline and trial evidence inform typical sequencing (examples: after 3 failed medication trials plus failed ECT, or after 4 failed medication trials).
CANMAT and multiple trials/meta‑analyses cited.
Investigational/not covered indications: rTMS/TMS is considered investigational for psychiatric/neurologic conditions beyond adult MDD, bipolar depression, and OCD and for alternate/novel TMS modalities (e.g., SNT/SAINT, synchronized TMS, low‑field magnetic stimulation) due to insufficient high‑quality evidence.
Coverage when guideline, regulatory, and payer criteria align
Coverage and clinical use are described relative to guideline and regulatory indications; apply when ALL relevant conditions are met per applicable payer rules and device labeling.
General coverage conditions: Patient meets DSM‑5 diagnosis for severe Major Depressive Disorder as specified by Medicare NCD/LCDs; prior inadequate response to antidepressant medication(s) consistent with device labeling or local coverage criteria; treatment delivered using an FDA‑cleared device for the specified indication (e.g., left prefrontal rTMS or deep TMS where indicated).
Device labeling (e.g., NeuroStar requiring failure of one 6‑week antidepressant course; Brainsway broader indication) and payer NCD/LCD requirements must be satisfied.
Key coverage criteria updates and applicability
Policy-level coverage stance and notable criteria changes in history entries
Medication trial requirements for MDD: TMS for Major Depressive Disorder requires failure of at least 3 different antidepressant medication trials (from at least 2 classes); theta‑burst stimulation is considered medically necessary when medical necessity criteria are met.3 failed trials
Change effective in 2015 and reinforced in 2022 updates.
Bipolar depression medication trials: Required failed medication trials for bipolar depression increased to 3 due to availability of additional medication options.3 failed trials
Documented in policy history updates.
Maintenance and repeat course denial logic: Maintenance TMS or repeat full/short intensive courses are not medically necessary if the preceding course was determined to be not medically necessary by the Company.
All TMS types and protocols that are not explicitly listed as medically necessary in this policy are considered investigational. Examples include, but are not limited to: accelerated TMS delivered at ≥3 treatments/day (including SNT/SAINT accelerated protocols), computer‑assisted transcranial magnetic stimulation of the prefrontal cortex (Group 8 technology), functional MRI–guided or MRI‑guided TMS, low‑field magnetic stimulation, magnetic seizure therapy (MeRT), multiarray or synchronized TMS, single‑pulse TMS, navigated TMS, and other novel/experimental coil or targeting methods. These modalities lack replicated, high‑quality evidence for clinical benefit outside the indications defined as medically necessary in this policy and therefore are not supported for routine coverage.
Use of TMS together with psychedelic therapies such as Spravato (esketamine), any form of ketamine, or other psychedelic agents is considered investigational and is not supported by the evidence base cited in this policy. Similarly, concurrent use of TMS with other neuromodulation modalities (for example, electroconvulsive therapy [ECT], deep brain stimulation [DBS], or cranial electrotherapy stimulation [CES]) is not considered medically necessary. An exception with specific limits is made for co‑use with vagus nerve stimulation (VNS) in specified situations (see VNS guidance): concurrent TMS may be medically necessary for defined intervals while awaiting VNS effect, but ongoing combined use is restricted by time and response criteria.
Evidence for rTMS in bulimia nervosa is very limited. A small randomized trial (n = 14) reported no evidence of efficacy; based on this and the absence of larger confirmatory studies, rTMS for bulimia nervosa is considered investigational.
FDA labeling and the pivotal randomized trial for the Cerena device indicate that the device has not been demonstrated as safe or effective for cluster headache, chronic migraine, or for treating migraine during the aura phase; associated migraine symptoms (photophobia, phonophobia, nausea) were not shown to be effectively relieved. Therefore, use of TMS devices for these migraine indications outside the approved labeling is not supported by the evidence presented.
rTMS/TMS for psychiatric or neurologic disorders other than adult Major Depressive Disorder (including bipolar depression where specified) and obsessive‑compulsive disorder is considered investigational. The available trials for other conditions are typically small, heterogeneous, and provide mixed or inconsistent results; large replicated, high‑quality trials are lacking, so routine medical necessity cannot be established for these other indications.
Devices or systems that do not have FDA clearance for the treatment of depression, or that are being used for conditions outside their cleared indications (for example, Cerena for migraine aura), are not supported by the depression‑specific regulatory indications discussed in this policy. Use of non‑cleared devices or off‑label device applications for non‑indicated conditions is therefore considered not supported by the evidence and treated as investigational in this policy.
Operational rules clarify that consecutive or overlapping courses of TMS for different diagnoses, simultaneous treatment with more than one provider or clinic, and brief overlapping courses started under different plans are generally considered not medically necessary. The policy also specifies restrictions on repeating courses and on continuation of TMS that began under a non‑Company plan unless prior medical necessity criteria were met.
TMS is not medically necessary when contraindications are present and not appropriately cleared (examples: presence or history of brain tumor, history of repetitive or severe head trauma, non‑removable magnetic‑sensitive implants near the coil, active psychotic disorder, uncontrolled substance abuse, or seizure disorder without stability/clearance). The policy also limits motor threshold re‑determination sessions (more than three such sessions without clinical justification is considered not medically necessary) and disallows more than allowed session frequencies (for example, more than two SNT/SAINT theta‑burst treatments per day).
Consecutive or overlapping courses of TMS for separate conditions, provision of TMS by multiple providers or clinics at the same time, and brief intensive courses that overlap prior short/brief courses are considered not medically necessary. The policy requires that when a prior course was furnished under a non‑Company plan, the prior course must have met medical necessity criteria to allow continuation or repeat under Company coverage.
The overall evidence base for many nonpharmacologic interventions and for some goals such as relapse prevention is limited and of low strength. Comparative research is early and hampered by heterogeneous definitions of treatment‑resistant depression and small study sizes; these evidence limitations reduce confidence in effectiveness estimates and may justify denial when documentation does not clearly meet coverage criteria.
Use of rTMS for other psychiatric or neurologic conditions beyond the policy's covered indications is considered investigational and therefore not medically necessary because the available trials are small, heterogeneous, and lack replication. Although some small studies report preliminary benefits for conditions such as PTSD, Parkinson disease motor symptoms, or auditory hallucinations in schizophrenia, durability and confirmatory evidence are insufficient to support routine coverage.
TMS for adolescents remains largely investigational for younger adolescents due to the limited, inadequately sized studies available. Evidence is more encouraging for older adolescents (post‑pubertal or approximately age 15 years and older) with emerging supportive data and a favorable safety profile, but randomized controlled evidence is still limited; therefore routine coverage for adolescents is restricted and cases may require individualized consideration.
Evidence for routine maintenance rTMS is limited and constitutes a major evidence gap. Published data on maintenance protocols are heterogeneous and mostly open‑label or uncontrolled; durability of acute responses varies and many patients relapse within months. Because high‑quality randomized data on maintenance benefit are sparse, routine, indefinite maintenance TMS is not supported by strong evidence.
Maintenance TMS is considered not medically necessary if the preceding intensive course was previously determined to be not medically necessary by the Company. The policy also clarifies repeat course rules: a repeat full intensive course is permitted only under defined conditions (prior positive response with recurrence after ≥90 days, or a documented rationale for a different technique or coil placement), and only one repeat full intensive course is generally allowed after a failed course.
Procedure and Product Codes
Listed CPT CodesCPT
0889T
Personalized target development for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation derived from a structural and resting- state functional MRI, including data preparation and transmission, generation of the target; motor threshold-starting location, neuronavigation files and target report;, review and interpretation.
0890T
Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including target assessment; initial motor threshold determination, neuronavigation, delivery and management; initial treatment day.
0891T
Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation; delivery and management; subsequent treatment day.
0892T
Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management; subsequent motor threshold redetermination with delivery and management; per treatment day.
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.
No explicit codes listed in this sectionmixed
No codes listed
Mentioned procedure codes/identifiersICD-10
X0ZX0X18
ICD-10 code indicating computer-assisted transcranial magnetic stimulation of the prefrontal cortex
Device/product codes and examples of FDA-cleared devicesmixed
OBP
FDA product code referenced for NeuroStar TMS
TMS CPT Codes moved into policyCPT
0889T
CPT code moved to this policy (procedure codes for TMS)
0890T
CPT code moved to this policy (procedure codes for TMS)
0891T
CPT code moved to this policy (procedure codes for TMS)
0892T
CPT code moved to this policy (procedure codes for TMS)
Historical diagnostic codes mentionedmixed
296.2x
ICD-9/ICD-10 era diagnostic code referenced in early history (mood disorder code added historically)
296.3x
ICD-9/ICD-10 era diagnostic code referenced in early history (mood disorder code added historically)
Maximum brief/booster course treatments — 10/15/20 by severity
Maximum treatments by severityMaximum of 10 treatments if symptoms are mild; 15 treatments if symptoms are moderate; 20 treatments if symptoms are severe.
Course frequencyOne treatment daily, 4–5 days per week for the brief/booster course.
Eligibility for boosterMay be considered when individual had a prior positive response and symptoms have worsened or during maintenance when symptoms worsen; not allowed if preceding course was determined not medically necessary.
Minimum medication trial duration to count as failed
Minimum duration to count as failed trial
Prior Authorization, Documentation, and Operational Steps
Prior Authorization
Maintenance TMS authorization limits
Initial authorization: Maintenance TMS may be approved for up to 12 weeks. Subsequent reauthorizations: up to 12 weeks when frequency is 2 treatments/week; up to 16 weeks when frequency is 1 treatment/week or 1 treatment every other week; up to 26 weeks when frequency is 1 treatment/month or less. Maintenance TMS (including resumption) is only considered medically necessary when prior clinical stability was achieved with maintenance TMS and improvement is being maintained. Maintenance, repeat full intensive, and short/brief intensive courses are not medically necessary if the preceding course was determined to be not medically necessary.
Initial maintenance authorization limit: 12 weeks
Reauthorization limits vary by frequency: 2/wk = 12 wks; 1/wk or every other week = 16 wks; 1/mo or less = 26 wks
Resumption permitted only if prior maintenance produced clinical stability
Prior Authorization
Prior authorization and required CPT listing
Prior authorization is required and requests must list the CPT codes and the number of sessions for each code. Include documentation that all medical necessity criteria are met and that the requested CPT-coded services correspond to the documented treatment plan.
Clinical Background, Evidence Summary, and Definitions
Transcranial magnetic stimulation (TMS) delivers rapidly changing magnetic fields via a coil placed on the scalp that induce weak electrical currents in superficial brain tissue. The induced electrical activity modulates neuronal firing and is thought to affect neurotransmitter release in cortical circuits involved in mood and other neuropsychiatric functions. TMS is a noninvasive neuromodulation technique with device‑ and protocol‑specific parameters (frequency, intensity, coil type, and targeting) that influence its clinical application.
Transcranial magnetic stimulation (TMS) — definition and mechanism
DefinitionTranscranial magnetic stimulation (TMS) uses an electromagnetic coil placed on the scalp to generate rapidly changing magnetic fields that induce electrical currents in superficial brain tissue to stimulate neuronal activity involved in mood regulation.
MechanismMagnetic pulses pass through the skull and induce weak electrical currents in targeted cortical regions, believed to modulate neurotransmitter release (e.g., serotonin, dopamine).
Modalities notedIncludes standard/conventional rTMS, deep TMS (H‑coil), and patterned protocols such as theta‑burst stimulation; device‑specific targeting and parameters vary by indication and trial evidence.
Modalities, Protocols, and Program Types
Settings and Level-of-Care Considerations
Session Counts, Course Limits, and Maintenance Frequency
TMS sessions — maximum total treatments for courses and extensions
Maximum total treatments for full coursesFull intensive courses typically described as 30 treatments over 6–7 weeks with optional 6‑treatment taper (total 30 or 36), or deep TMS courses described as 40–44 treatments (or 30/36 with taper) depending on protocol.
Extension limitsExtensions of intensive courses allow a maximum of 10 additional treatments for mild symptoms, 15 for moderate, and 20 for severe symptoms per extension rules.
Maintenance frequency capMaintenance rTMS frequency considered medically necessary is 2 treatments per week or less; a variety of tapered or clustered monthly schedules have been reported.
Short/brief intensive (booster) TMS course — Maximum of 10/15/20 treatments
Short/brief intensive (booster) maximumsMaximum of 10 total treatments for mild symptoms, 15 for moderate, and 20 for severe symptoms for a short/brief intensive (booster) course.
Policy Revision History
2025-10-01annual_reviewLatest
Added criterion allowing resumption of maintenance TMS when previous maintenance treatment had been stopped; moved CPT codes 0889T-0892T into this policy from policy 10.01.533 to align coding with criteria.
2024-11-01interim_review
Deleted 'Substance use disorder unless in early or sustained remission' as a contraindication to TMS.
2024-10-01
Policy Summary
PayerPremera Bluecross
PolicyTranscranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Policy CodePolicy 2.01.50
Change TypeMaterial updates to coverage criteria and operational CPT code relocation
Effective DateOct 1, 2025
Next Review DateN/A
Key ActionInclude prior authorization with documentation of diagnosis, standardized severity rating, and prior medication trials when requesting TMS.
Maintenance TMS: May be considered medically necessary when an intensive TMS course resulted in improvement; frequency of 2 treatments/week or less. Initial authorization up to 12 weeks; subsequent reauthorization durations depend on frequency (up to 12 weeks for 2/wk, up to 16 weeks for 1/wk or every other week, up to 26 weeks for monthly or less). Motor threshold re‑determination no more frequently than every 10 sessions unless clinically indicated.frequency <=2/week
Maintenance is not medically necessary if improvement is not maintained or the preceding intensive course was determined not medically necessary.
May be medically necessary when the individual had a prior positive response and symptoms have worsened or during maintenance with documented worsening; no booster within prior 90 days; course is one treatment daily (4–5 days/week) with maximum treatments per severity (10/15/20).
no booster within 90 days
Motor threshold re‑determination allowances per severity; not medically necessary if prior course was non-covered.
Concurrent modality rules: Use of TMS in conjunction with Spravato (esketamine), ketamine, or any psychedelic drug is investigational. Use of TMS with VNS may be medically necessary for up to 3 months after VNS implantation while awaiting VNS effect and may be extended for up to three additional 3‑month intervals if no improvement; continued TMS is not medically necessary when depression improves to mild/remission or after 12 months post‑implantation. Use of other neuromodulation modalities (ECT, DBS, CES) with concurrent TMS is not medically necessary.max 12 months with VNS
See VNS guidance and investigational modalities in exclusions.
Bipolar and MDD-specific notes: Diagnosis with a severity numeral alone is insufficient; require standardized rating scale or documented symptom severity. For bipolar depression, mixed episodes are not equivalent and TBS is investigational. Augmenting agents (second‑generation antipsychotics, lithium, anticonvulsants) are considered augmenting, not antidepressants; antidepressant‑dose thresholds apply for certain agents.N/A
Refer to Additional Information for medication dosing examples and documentation rules.
Direct comparisons mixed; pooled meta‑analysis favored ECT over rTMS for remission (pooled OR 0.46), though some trials found no difference.
n/a
Evidence strength limited and heterogeneous.
Maintenance rTMS: Various maintenance tapering schedules and clustered monthly maintenance have been used; durability of benefit is mixed with many relapsing within months though some patients maintain response with tapered protocols.various schedules reported
Maintenance evidence is limited and heterogeneous.
Migraine device indications are limited and distinct from depression indications.
Adolescents generally investigational for younger ages; older adolescents may be eligible under specific criteria.
VNS timing guidance: VNS may require up to 3 months to demonstrate effect; TMS may be continued during this period (with reassessment at 3‑month intervals) and is not continued beyond 12 months post‑implantation if VNS has not shown benefit or when depression improves to mild/remission.assessment at 3‑month intervals; max 12 months
See VNS‑TMS concurrent modality rules.
preceding course NMN
Added effective 01/01/24 annual review.
Contraindications requiring specialist evaluation: Presence of a brain tumor, history of brain tumor, or history of repetitive/severe head trauma are contraindications unless a neurologist or neurosurgeon has documented that the individual can safely undergo TMS.specialist evaluation documentation
Clarified in 07/01/24 and subsequent updates.
Minimum of 30 continuous days at a therapeutic dose is required for a medication trial to be considered failed unless stopped for intolerable adverse effects.
Failure reasons must be specifiedEach failed medication must be individually identified and the reason(s) for failure specified (inefficacy, partial response, loss of effect, intolerable adverse effects, or inability to titrate to therapeutic dose).
ExceptionIf medication was stopped because of intolerable adverse effects, the 30-day minimum does not apply.
Number of prior antidepressant failures
Typical trial counts in studiesTrials commonly define TRD as failure of ≥1 adequate antidepressant trial in the current episode; many studies used ≥2 failed adequate trials.
Payer expectation contextClinical trial evidence and practice typically require documentation of prior adequate antidepressant trials (commonly ≥1 to ≥2 failed trials in the index episode) to justify rTMS.
Variation across evidenceDefinitions of prior antidepressant failures vary across studies and trials; confirm device labeling or payer criteria for exact thresholds.
Failed antidepressant trial example
Example from device labelingNeuroStar TMS specifies failure of one 6‑week course of antidepressant medication as a prior trial in its indication.
Clinical documentationProviders should document prior treatment and diagnosis consistent with device labeling when applicable (e.g., one 6‑week failed course for NeuroStar).
Context in trialsSome RCTs required failure of at least one adequate antidepressant course; trial definitions vary by study and device indication.
Failed medication trials for Major Depressive Disorder
MDD medication trial threshold>= 3 different antidepressant medication trials required for Major Depressive Disorder (policy reduced requirement from 4 to 3 trials).
Basis for changeChange noted in policy history (2022 update) reducing MDD medication trial requirement from 4 to 3 failed trials.
Device-specific exceptionsSome FDA device indications (e.g., NeuroStar) specify failure of one adequate antidepressant course; follow device labeling where applicable.
Failed medication trials for Bipolar Depression
Bipolar depression medication trials>= 3 medication trials required for bipolar depression (policy increased requirement from 2 to 3).
Examples of medicationsPolicy lists mood‑stabilizing or bipolar medications (e.g., lithium, lamotrigine, cariprazine, quetiapine, olanzapine-fluoxetine) among options to document failure.
Age and severity requirementsBipolar depression coverage applies for adults with documented moderate‑to‑severe depression without psychotic or manic features and required medication failures.
Required to list CPT codes and session counts (e.g., 90867, 90868, 90869, 0889T-0892T)
Attach medical records demonstrating criteria are met
Documentation Required
Prior treatment failure and documented response required
Prior authorization requests must document prior treatment failures and measured response. For unipolar major depressive disorder, document failure of at least three adequate antidepressant trials (or two plus an augmenting agent) as specified in policy; for bipolar depression, document the required medication trial failures per policy.
Each failed medication must be listed with reason for failure (ineffective, intolerable adverse effect, lost response)
Minimum duration: at least 30 continuous days at therapeutic dose unless stopped for intolerable adverse effects
Documentation Required
Evidence-based justification required
Provide an evidence-based justification in the prior authorization submission: identify the DSM-5 diagnosis, current severity (standardized rating scale scores or narrative), prior treatments tried (medications, ECT, psychotherapy), dates and outcomes, and the clinical rationale for TMS citing limited and mixed evidence where applicable.
State diagnosis and rationale for choosing TMS given prior treatments
Reference relevant device labeling or evidence when applicable
Prior Authorization
Prior authorization: confirm diagnosis and prior treatment
Prior authorization reviewers will confirm that the DSM-5 diagnosis, prior antidepressant trials, and other policy criteria are met. Coverage determinations are tied to applicable Medicare NCD/LCDs and FDA device clearances when relevant.
CPT codes 0889T–0892T (accelerated functional connectivity MRI-guided theta-burst stimulation and related planning/management codes) have been moved into this policy. Prior authorization applies and the submission must include these CPT codes where used.
Codes moved into this policy: 0889T, 0890T, 0891T, 0892T
Traditional TMS codes (90867, 90868, 90869) also require authorization per criteria
Denial Risk
Contraindications that trigger noncoverage
Requests lacking documentation of absolute or policy-listed contraindications clearance will be denied. Examples that trigger noncoverage include presence of a brain tumor without documentation that a neurologist/neurosurgeon has evaluated the individual and cleared TMS; implanted magnetically-sensitive materials within 30 cm of coil placement (except certain dental work); non‑MRI‑safe implanted stimulators without physician documentation; active psychotic disorder or uncontrolled seizure disorder (unless exceptions per policy documented).
Brain tumor or lesion without neurology/neurosurgery clearance = noncoverage trigger
Non-removable ferromagnetic/ conductive implants near coil = noncoverage
Uncleared implanted stimulators or active psychosis/seizure without policy-based exception = noncoverage
Denial Risk
Evidence limitations may trigger denial
Insufficient evidence, low-strength evidence, or requests for investigational indications (conditions other than MDD, bipolar depression, and OCD) may trigger denial. Varying definitions of treatment-resistant depression (TRD) and lack of adequate documentation of prior trials/outcomes are common reasons for noncoverage.
Requests for rTMS for indications other than MDD, bipolar depression, or OCD are likely investigational
Lack of documented adequate prior trials or inconsistent TRD definitions may lead to denial
Note
Medicare coverage constraints
Medicare coverage constraints: Medicare NCD and applicable LCDs cover left prefrontal rTMS for patients meeting DSM-5 criteria for severe MDD and other NCD/LCD-specific requirements. Prior authorization may still be required; ensure the request aligns with NCD/LCD language and device labeling.
Confirm alignment with Medicare NCD/LCD when member is Medicare
Coverage limited to left prefrontal rTMS per NCD/LCD criteria
Documentation Required
Required documentation for review
Required documentation for review: medical records must include diagnosis, severity of symptoms (standardized rating scale scores or narrative), brief history of the current episode, age, detailed medication trials with outcomes (including dates, doses, duration, reason for discontinuation), contraindications and neurologic clearances when applicable, and the CPT codes and number of sessions requested.
Medication trials with outcomes, dates, doses, duration, and reasons for failure
CPT codes and number of sessions requested
Neurology/neurosurgery clearance when indicated by contraindication
Documentation Required
Prior treatment failure and outcome measurement
Prior treatment trials should document outcomes using standardized outcome measures when available. Use validated depression rating scales (HAM-D, MADRS, PHQ-9) to show baseline severity, response, remission, or relapse. Document motor threshold determinations and any changes to stimulation parameters with clinical rationale.
Provide baseline and follow-up standardized scale scores
Document prior antidepressant trial outcomes and duration
Record motor threshold assessments and rationale for parameter changes
Documentation Required
Submit study-specific details
When coverage is being requested based on evidence from a specific study or protocol (e.g., accelerated, MRI-guided protocols), submit study-specific details: trial design, patient population, number of prior treatment failures in the referenced study, outcomes, and how the member matches study eligibility and protocol.
Include study design and outcomes if relying on trial evidence for coverage
Explain how member characteristics align with study population and device labeling
Documentation Required
Support DSM-5 diagnosis and NCD/LCD criteria
Support DSM-5 diagnosis and NCD/LCD criteria in the submission. For Medicare patients, explicitly state how the member meets DSM-5 criteria for severe MDD and other NCD/LCD elements. For device-specific indications, reference FDA-cleared labeling (e.g., NeuroStar, Brainsway) and show prior trials required by labeling when applicable.
Explicitly map clinical information to DSM-5 diagnostic criteria and NCD/LCD requirements
Cite FDA device indications when relevant
Documentation Required
Required documentation for safety and severity
Required documentation for safety and extension decisions: when requesting treatment extension, motor threshold re-determination, or changes in pulse/frequency parameters, include standardized rating scale scores demonstrating current severity or maintenance, documentation of safety monitoring, and justification for parameter changes or extended timeframes.
Standardized scale scores required for extension or continuation decisions
Clinical justification and safety documentation for pulse/frequency changes or additional motor threshold sessions
Prior medication failure requirement & Medication trial requirements before TMS
Medication trial requirements and prior medication failure: For unipolar MDD, TMS is medically necessary after documented failure of at least 3 antidepressant medications from at least 2 classes, OR failure of at least 2 different antidepressants from ≥2 classes plus failure with an augmenting agent. Each failed medication must be named with dose, duration (minimum 30 continuous days unless stopped for adverse effects), and reason for failure.
Minimum duration for a failed trial: 30 continuous days at therapeutic dose unless intolerable adverse effects
Documentation Required
rTMS commonly used after antidepressant failure & Document prior/concurrent standard treatments
rTMS is commonly used after failure of antidepressant medications. Clinical trials typically enrolled individuals who had failed ≥1 and often ≥2 adequate antidepressant trials; this policy expects documentation of the specified number of failed trials before TMS is authorized. Also document prior or concurrent standard treatments (psychotherapy, pharmacotherapy, ECT) where applicable.
Document that rTMS is being considered after appropriate medication trials per policy
List prior/concurrent standard treatments (psychotherapy, ECT, augmenting agents) and outcomes
Clinical response defined as >=50% improvement on HAM-D
Clinical response definitionClinical response is defined as an improvement of 50% or more on the Hamilton Depression Rating Scale (HAM‑D).
Use in trialsResponse thresholds such as ≥50% HAM‑D improvement are commonly used as primary efficacy outcomes in rTMS trials.
Documentation implicationStandardized rating scales (HAM‑D, MADRS) are expected documentation to assess baseline severity and response for coverage decisions.
Treatment-resistant depression (TRD) — variable definitions across studies
Variable definitionsTreatment‑resistant depression (TRD) definitions vary across studies; commonly defined as failure of ≥1 adequate antidepressant trials in the current episode, with many studies using ≥2 failures.
Trial contextLargest multicenter rTMS trial defined TRD as failure of at least one adequate antidepressant course; participants averaged 1.6 failed treatments in the current episode.
Implication for coverageBecause TRD definitions vary, confirm payer/device-specific prior treatment thresholds when documenting eligibility for TMS.
High intensity / low frequency rTMS — stimulation parameter examples
Examples of stimulation parametersHigh‑frequency examples include 10 Hz (commonly used for left DLPFC); low‑frequency example includes 1 Hz (often used over right DLPFC); some protocols use priming or other parameter variations.
Session schedulesTypical acute course schedules in trials used daily sessions Monday–Friday for several weeks (e.g., 4–6 weeks).
Device/target dependenceFrequency and intensity choices vary by cortical target and device; outcomes may be influenced by targeting and stimulation intensity.
SNT/SAINT and theta burst stimulation — definitions and evidence caveats
SNT/SAINT definitionSNT/SAINT is an accelerated theta‑burst protocol consisting of 10 theta‑burst sessions per day for 5 consecutive days (recently FDA‑cleared), sometimes described as accelerated high‑dose functional connectivity MRI‑guided theta‑burst stimulation.
Evidence caveatsPublished studies of SNT/SAINT are small, non‑replicated, and include uncontrolled or underpowered trials; durability and generalizability remain uncertain, so accelerated protocols are considered investigational in many contexts.
fMRI/targeting noteSome accelerated theta‑burst protocols incorporate functional MRI personalized target development and neuronavigation; these approaches are new and evidence is limited.
rTMS — definition
Definition of rTMSRepetitive transcranial magnetic stimulation (rTMS) delivers repeated magnetic pulses to a cortical target (e.g., left DLPFC) using an electromagnetic coil placed on the scalp.
PurposeUsed in trials and clinical practice to treat major depressive disorder after inadequate response to antidepressant medications.
Typical deliveryDelivered in daily sessions (commonly 4–5 days/week) over several weeks depending on protocol and device.
Deep TMS — definition and H-coil mention
Definition of deep TMSDeep TMS uses H‑coil technology to stimulate deeper and broader cortical regions compared with standard coils (Brainsway H‑Coil is an example).
Regulatory noteDeep TMS has separate FDA device clearance and was supported by a multicenter randomized trial demonstrating per‑protocol response and remission benefits.
Course variantsDeep TMS full courses described in trials include 20‑44 total treatments depending on intensive and continuation phases or 30 with optional tapering.
Theta-burst stimulation (TBS/iTBS) — alternative patterned TMS protocol
TBS definitionTheta‑burst stimulation (TBS/iTBS) is a patterned TMS protocol (intermittent TBS commonly) shown in trials to be non‑inferior to standard high‑frequency rTMS for depression.
Evidence baseSystematic reviews and randomized trials (e.g., THREE‑D, meta‑analyses) support TBS effectiveness for major depressive disorder in adults, but accelerated TBS protocols have limited/early evidence.
Clinical useTBS is now included among modalities considered medically necessary for adult MDD when criteria are met (policy updates 2022).
Repetitive transcranial magnetic stimulation — rTMS shorthand definition
rTMS shorthandrTMS stands for repetitive transcranial magnetic stimulation.
UsageCommon abbreviation used throughout policy and trials to denote repeated-pulse TMS protocols.
Related termsIncludes variants such as deep TMS and theta‑burst stimulation under the broader rTMS category.
TRD shorthandTRD stands for treatment‑resistant depression.
Common operational definitionOften defined as failure of ≥1 adequate antidepressant trials in the current episode; many studies use ≥2 failures.
Coverage implicationBecause definitions vary across studies, payer/device criteria should be checked for the specific required number of failed trials.
Motor threshold — MT definition
Motor threshold (MT) definitionMotor threshold (MT) is the stimulation intensity used to determine the minimum magnetic field required to elicit a motor response; initial motor threshold determination may be done at first session and re‑determination allowed 1–3 times as specified.
Re‑determination limitsMore than three treatment sessions that include motor threshold re‑determination are considered not medically necessary except in specific circumstances such as equipment problems or clinical need to change parameters.
DocumentationMotor threshold determination and any re‑determinations should be documented in the medical record as part of treatment planning and delivery.
Outpatient procedural TMS treatment courses include several defined course types: a full intensive course (commonly 30 treatments over 6–7 weeks with an optional taper totaling 30 or 36 treatments, or device‑specific courses of 40–44 treatments for deep TMS), short/brief intensive (booster) courses (limited to a maximum of 10 treatments for mild, 15 for moderate, or 20 for severe symptoms), accelerated courses (limited to 2 treatments/day with no change in total treatment count for hardship situations), and maintenance courses (reduced frequency, typically ≤ 2 treatments/week, with initial authorizations and reauthorization durations specified). These outpatient TMS programs are generally delivered in ambulatory settings and require documentation of diagnosis, baseline severity, prior treatment failures, and absence of contraindications or appropriate specialist clearance when indicated.
Minimum interval before repeat boosterA short/brief intensive course is not allowed if a short/brief intensive course was given in the past 90 days.
ScheduleDelivered as one treatment daily, 4–5 days per week during the booster course.
Maintenance schedules varyMaintenance rTMS schedules reported include tapered regimens (e.g., from 3×/week to monthly over ~20 weeks) and clustered monthly maintenance (e.g., 5 sessions over 2.5 days monthly).
Authorization limitsInitial authorization for maintenance TMS may be approved for up to 12 weeks; subsequent reauthorizations vary by frequency (policy guidance).
Evidence gapHigh‑quality evidence for maintenance rTMS is limited and durability varies; documentation of sustained benefit is expected for continued authorization.
TMS sessions — number of sessions per course and allowed extensions
Course session examplesFull courses: standard rTMS 30 treatments over 6–7 weeks (optional 6‑treatment taper to 36); deep TMS options include 20 treatments plus continuation to total 40–44 or 30 with optional taper to 36.
Allowed extensionsExtensions permitted as one treatment daily 4–5 days/week with maximum additional treatments of 10 (mild), 15 (moderate), or 20 (severe); additional extensions possible if improvement documented but not to remission.
RestrictionsMaintenance or repeat courses are not medically necessary if the preceding course was determined not medically necessary; more than three motor threshold re‑determination sessions is not medically necessary except for specified reasons.
interim_review
Added seizures due to substance (alcohol or drug) withdrawal as a circumstance in which seizure history is not a contraindication when the individual is abstinent.
2024-07-01annual_review
Clarified contraindications: presence or history of brain tumor and history of severe/repetitive head trauma require neurologist or neurosurgeon documentation that the individual can safely undergo TMS; added unspecified brain lesion with same requirement.
2024-01-01annual_review
Added criteria that maintenance TMS, repeat full intensive courses, or short/brief intensive courses are not medically necessary if the preceding course was determined to be not medically necessary.
2023-05-01interim_review
Clarified that a seizure history is not a contraindication if seizures were due to adverse drug effects or interactions and added examples expanding accelerated TMS hardship exceptions and continuation criteria for TMS started under a non-Company plan.
2023-04-14historical_update
(Recorded earlier) 2015–2017 and 2016 updates reorganized and clarified types of TMS considered medically necessary (standard repetitive and deep TMS) versus investigational and updated coding and policy formatting in subsequent annual reviews.
2015-04-14interim_update
Added medically necessary policy statement for Major Depressive Disorder including failure of at least 3 different antidepressant medication trials and updated guidelines (removed pregnancy as a contraindication at that time).
2013-01-14policy_creation
Policy created with investigational stance for all indications and initial history entry documenting consideration of TMS indications and evidence base beginning in 2013.