Currentpriority healthPolicy N/A

Transcranial Magnetic Stimulation (TMS) Coverage Criteria

Policy governing medical necessity, authorization, documentation, and billing requirements for transcranial magnetic stimulation for depressive disorders for Priority Health members; applies to commercial, Medicare, and Medicaid lines as specified.

Policy Summary

Payerpriority health

PolicyTranscranial Magnetic Stimulation (TMS) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest authorization for TMS (in-network via GuidingCare; out-of-network via TMS authorization form) and include required documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 20+5Initial course length covered

+10+6Extension when ≥25% improvement

not coveredMaintenance therapy stance

requiredAuthorization requirement

18+Age

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Covered indications and treatment course

Covered when ALL of the following are met

Eligibility and indication: Patient is 18 years or older with a major depressive episode/major depressive disorder who failed to improve on antidepressant medicationsage >= 18

Standard repetitive TMS and deep TMS have demonstrated effectiveness for this population

Initial treatment course: Initial course up to 20 sessions over a 4-week period, followed by 5 tapering sessions for patients who achieve remission<=20 sessions in 4 weeks + 5 taper

Authorization required; device must be FDA‑approved

Extension criteria: Patients demonstrating at least 25% improvement on validated depression rating scales may receive an additional 2 weeks (10 sessions) with 6 additional tapering sessions>=25% improvement

Extension limited to specified additional sessions and must be documented with validated scales (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS, IDS-SR)

Retreatment criteria: Retreatment allowed for relapse when prior TMS met documented response (>50% improvement) or for relapse following remission; retreatment should follow the initial protocol>50% prior improvement

Documentation of prior response required

Maintenance TMS therapy is considered experimental/investigational and is not deemed medically necessary.

Maintenance/maintenance-phase TMS is not medically necessary (experimental/investigational) and therefore is excluded from coverage.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Authorization is required for TMS services. In-network providers must request authorization via GuidingCare. Out-of-network providers must request authorization using the Priority Health Transcranial Magnetic Stimulation (TMS) authorization form. Requests must document: current diagnosis; onset of current depressive episode; dates of current or recent outpatient therapy; a copy of the depression screening tool completed by the member; notation of all medication trials completed; and information regarding any medical contraindications. The treatment must be provided using an FDA‑approved TMS device.

Required with authorization: Current diagnosis
Required with authorization: Onset of current depressive episode
Required with authorization: Dates of current or recent outpatient therapy
Required with authorization: Copy of completed depression screening tool (e.g., PHQ‑9, HAM‑D, MADRS, etc.)
Required with authorization: Notation of all antidepressant medication trials completed
Required with authorization: Information regarding any medical contraindications
In‑network authorization pathway: GuidingCare
Out‑of‑network authorization pathway: Priority Health TMS authorization form

Step Therapy

Medication Failure Prerequisite

Prior adequate antidepressant medication trials are required before TMS is authorized. Providers must document the medication trials (agents, doses, durations, and reason for discontinuation if applicable) as part of the authorization request.

Document medication trials: agent, dose, duration, response, and reason for discontinuation

Documentation Required

Required Documentation With Authorization

Complete and thorough documentation to substantiate the procedure is the responsibility of the provider. The attending physician must monitor and document the patient's clinical progress throughout treatment using evidence‑based, validated depression assessment tools (acceptable instruments include GDS, PHQ‑9, BDI, HAM‑D, MADRS, QIDS, IDS‑SR). Maintain documentation of the procedure performed, device used (FDA approval), session counts, treatment dates, and clinical response measures.

Use validated depression rating scales for baseline and ongoing monitoring (e.g., PHQ‑9, HAM‑D, MADRS, QIDS, IDS‑SR, BDI, GDS)
Document device used and confirm FDA approval for intended use
Document session dates, number of sessions, and treatment parameters
Include clinical response documentation and any adverse events

Denial Risk

Documentation and Coding Errors — Denial Risk

Failure to follow billing and coding requirements or to document services rendered may result in claim denial, rejection, or recoupment. An authorization does not guarantee payment — claims must be billed with industry‑standard, compliant CPT/HCPCS/revenue codes and supported by the medical record. Priority Health may perform pre‑ or post‑payment reviews to validate billing and coding accuracy; noncompliance may lead to denial, recovery, or recoupment of payment.

An authorization does not supersede coding, billing, or reimbursement requirements
Use correct, fully specific CPT/HCPCS and revenue codes only when the service was performed and documented
Failure to document services rendered will result in denial
Priority Health may reject/deny claims or recover payment for noncompliant billing

Background

Transcranial magnetic stimulation (TMS) delivers repeated magnetic pulses to targeted brain areas to stimulate neurons and relieve symptoms of major depressive episodes. Priority Health covers an initial course of TMS of up to 20 sessions over a 4‑week period, followed by 5 tapering sessions for patients who achieve remission. Patients demonstrating at least a 25% improvement on validated depression rating scales may receive an extension of 10 additional sessions over 2 weeks with 6 tapering sessions. Retreatment for relapse is allowed when prior TMS produced a documented response of greater than 50% improvement, and must follow the initial treatment protocol. Authorization is required and requests must include current diagnosis, onset of the current depressive episode, dates of recent outpatient therapy, a completed depression screening tool, notation of all completed medication trials, and any medical contraindications.

OpenPayer

Transcranial Magnetic Stimulation (TMS) Coverage Criteria

Coverage Criteria for TMS

Billing and Coding Guidance

Provider Requirements and Authorization

Background

Definitions

Level of Care — Outpatient Treatment

TMS Treatment Modalities

Visit Limits and Session Counts