UnitedHealthcare TMS Coverage Update

Coverage Criteria and Evidence Summaries

inv-01: Not medically necessary / Unproven indications

Covered status and medical necessity stance

Primary stance: Transcranial magnetic stimulation for treating all medical (non‑behavioral) conditions is considered unproven and not medically necessary due to insufficient evidence of efficacy.

Includes, but is not limited to, Alzheimer disease; chronic neuropathic pain; dystonia; epilepsy; headaches; Parkinson disease; stroke; tinnitus; traumatic brain injury; navigated TMS for treatment planning/diagnosis; and theta‑burst stimulation including accelerated and MRI‑guided protocols.

inv-02: Epilepsy — Evidence summary (inconsistent RCTs; low/very-low certainty)

Evidence from randomized trials is inconsistent and low to very low certainty.

Epilepsy evidence summary: Eight randomized trials (241 individuals) in a Cochrane review provided inconsistent effects of rTMS on seizure frequency: two trials reported large seizure reductions while six did not; some trials showed reductions in epileptiform discharges; adverse events were uncommon but increased seizure frequency occurred in a few individuals. Overall certainty of evidence was judged low to very low.

Cochrane review results and earlier reviews noted methodological heterogeneity, inability to meta-analyze across trials, and low/very-low certainty.

inv-03: Headaches / Migraine — Evidence summary (multiple systematic reviews and RCTs; heterogeneous/preliminary)

Multiple systematic reviews and RCTs report promising but heterogeneous and preliminary evidence for rTMS in migraine.

Migraine evidence summary: Randomized trials and meta-analyses report that HF-rTMS and other neuromodulation approaches can reduce migraine frequency or monthly migraine days in some studies, but effect estimates, optimal stimulation sites (eg, left DLPFC, C3, M1), and protocols vary widely; study heterogeneity, small sample sizes, short follow-up, and inconsistent outcomes limit conclusions. NICE advises use only with special arrangements (governance/research).

Findings derive from multiple RCTs and systematic reviews/network meta-analyses highlighting promising but preliminary and heterogeneous evidence.

inv-04: Parkinson disease — Evidence summary (modest short-term motor benefit; uncertain parameters/long-term effects)

Systematic reviews and RCTs show modest short-term motor benefit; parameters and long-term effects uncertain.

PD evidence summary: Multiple RCTs and meta-analyses indicate rTMS may provide modest short-term motor improvements in Parkinson disease (including benefits for freezing of gait and some cognitive measures). Higher-frequency stimulation over M1, bilateral stimulation, multisession protocols, and higher total pulse counts (eg, ~18,000–20,000 pulses) were associated with larger effects in some analyses. Heterogeneity, small study sizes, and unclear optimal parameters limit definitive conclusions about long-term benefit and standard protocols.

Evidence includes short-term pooled motor score improvements but requires further high-quality trials to establish optimal parameters and durability.

inv-05: Pain / Neuropathic pain — Evidence summary (mixed evidence; some positive signals for neuropathic pain and DLPFC stimulation)

Evidence mixed across pain etiologies; some positive signals for neuropathic pain and DLPFC stimulation.

Pain evidence summary: Randomized trials and systematic reviews report mixed results across pain conditions. Some RCTs and meta-analyses show modest short-term analgesic effects of HF-rTMS applied to M1 or left DLPFC for neuropathic pain (eg, SCI, diabetic peripheral neuropathy), with statistically significant but often small effect sizes; other pooled analyses found no significant overall benefit (particularly post-SCI). Evidence certainty ranges from very-low to low and study heterogeneity and small sample sizes are common.

Some meta-analyses reported transient reductions in pain and potential for multiple sessions to sustain effect, but clinical significance often did not meet minimal important difference thresholds.

inv-06: Evidence-based coverage considerations

Summary of evidence-based findings relevant to coverage decisions for rTMS/NIBS by indication.

Neuropathic pain (general): Systematic reviews report transient pain reduction with M1 HF-rTMS in some neuropathic pain types; evidence is heterogeneous with certainty ranging from very-low to low. Multiple-session protocols may sustain longer effects, but clinically important differences are not consistently met.

See systematic reviews and meta-analyses reporting short-term WMDs and percent pain reductions.

Post-spinal cord injury neuropathic pain: Meta-analyses did not find a significant effect of rTMS or other NIBS modalities on neuropathic pain after SCI; routine clinical use is not supported.

Based on pooled analyses showing no significant benefit in SCI neuropathic pain.

Stroke motor recovery: Systematic reviews and network meta-analyses of RCTs report that certain rTMS modalities (eg, LF-rTMS for Fugl-Meyer motor scores; HF-rTMS for some speed or MEP amplitude outcomes) can improve specific motor outcomes after stroke, but studies are heterogeneous and evidence is preliminary.

Network meta-analysis included 26 RCTs (lower extremity outcomes) with mixed modality-specific effects.

inv-07: nTMS and TBS evidence summaries

Evidence-based summaries for nTMS and theta-burst stimulation (TBS).

nTMS for preoperative mapping: Navigated TMS used for preoperative motor and language mapping is supported by systematic reviews and observational studies showing associations with reduced postoperative permanent motor deficits and increased gross total resection rates; however, high-level randomized trial evidence is limited and further RCTs are needed.evidence observational/meta-analytic

Meta-analyses report reduced odds of permanent motor deficits (OR ~0.54) and increased GTR (OR ~2.32) in observational series.

Theta-burst stimulation (TBS): Accelerated, repetitive, MRI-guided TBS and other accelerated TBS protocols currently lack sufficient RCT evidence demonstrating safety and clinical effectiveness; existing trials are small and inconclusive, and accelerated/MRI-guided protocols should be considered investigational pending more data.insufficient RCT evidence

Limited trial evidence for accelerated or MRI-guided TBS; safety and efficacy not established.

inv-08: Professional society positions

Professional guideline statements and recommendations relevant to TMS use.

AAN guidance: AAN indicates rTMS is possibly effective (level C) for primary moderate to severe restless legs syndrome based on limited evidence; for tics in Tourette syndrome the evidence is insufficient to support rTMS or continuous TBS interventions.guideline recommendation

AAN guidelines (Winkelman et al. 2016; Pringsheim et al. 2019) provide condition-specific guidance.

AAO-HNS guidance: The AAO-HNS guideline advises clinicians should not recommend TMS for persistent, bothersome tinnitus.recommendation against use

AAO-HNS clinical practice guideline recommends against TMS for persistent tinnitus.

European and NICE positions: European Headache Federation and NICE express caution: EHF states rTMS for chronic headaches is not yet evidence-based; NICE recommends TMS for migraine only with special arrangements for clinical governance, consent, audit, or research.

This policy does not address behavioral health indications. For behavioral disorders, including psychiatric uses of TMS, refer to the Optum Behavioral Clinical Policy titled "Transcranial Magnetic Stimulation." Requests for TMS to treat behavioral conditions should be managed under that behavioral policy rather than this document.

Noninvasive rTMS for chronic headaches and migraine is not established as standard care. The NICE guideline (2014) states evidence for TMS to treat or prevent migraine is limited and advises use only with special arrangements for clinical governance, consent, audit, or research. The European Headache Federation likewise indicates that application of noninvasive rTMS in chronic headaches is currently not evidence based because of the limited controlled data.

The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) clinical practice guideline for tinnitus advises that clinicians should not recommend transcranial magnetic stimulation for patients with persistent, bothersome tinnitus.

The AAO-HNS guideline provides an explicit recommendation against using TMS to treat persistent, bothersome tinnitus and therefore clinicians should follow that guidance when making treatment decisions for tinnitus patients.

Coverage determinations under this policy must be reconciled with the member-specific benefit plan document. In the event of any difference between this policy and a member's plan terms, the member-specific benefit plan governs and should be verified before authorizing services.

This policy addresses transcranial magnetic stimulation applied to medical (non‑behavioral) conditions

Pooled evidence does not support routine use of noninvasive brain stimulation (NIBS), including rTMS, for neuropathic pain after spinal cord injury. A meta-analysis of available trials found no significant effect of rTMS, tDCS, or cranial electrotherapy stimulation on post‑SCI neuropathic pain, and therefore routine clinical use is not supported.

Because meta-analyses and systematic reviews report little or inconsistent benefit and evidence quality is generally very low to low for many chronic pain indications, NIBS (including rTMS, tDCS, and CES) is not supported for routine use in post‑spinal cord injury neuropathic pain and similar chronic pain conditions without clearer demonstration of clinically important benefit.

Accelerated, MRI‑guided theta‑burst stimulation protocols lack sufficient evidence of clinical benefit and safety. Studies demonstrating clinical use and safety of accelerated, MRI‑guided TBS are currently lacking, so these accelerated TBS approaches cannot be concluded to provide a beneficial effect on health outcomes.

The document does not contain additional explicit statements labeling specific interventions as 'not medically necessary' beyond those summarized in the policy sections; however, coverage determinations must still follow the member-specific benefit plan and applicable mandates.

Applicable Codes and Device Identifiers

Applicable Codes (listed)CPT

0858T	Externally applied transcranial magnetic stimulation with concomitant measurement of evoked cortical potentials with automated report.
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.

FDA device product codes (informational)mixed

GWF, HAW, IKN, OBP, OCI, OKP

FDA product codes referenced for Transcranial Magnetic Stimulation devices (informational list).

Provider Actions, Prior Authorization, and Documentation

Denial Risk
Not Medically Necessary for Listed Medical Conditions
Requests to use transcranial magnetic stimulation (TMS) for listed medical (non‑behavioral) conditions are considered not medically necessary due to insufficient evidence of efficacy. Do not submit prior authorization expecting coverage for TMS to treat medical conditions listed in the policy; verify member-specific benefits for any exceptions.
Alzheimer disease
Chronic neuropathic pain
Dystonia
Epilepsy
Headaches
Parkinson disease
Stroke
Tinnitus
Traumatic brain injury
Navigated TMS for treatment planning/diagnosis
Theta-burst stimulation, including accelerated and MRI‑guided protocols

Background on TMS and Related Techniques

Transcranial magnetic stimulation (TMS) is a noninvasive method of delivering electromagnetic pulses to the brain. Single‑pulse TMS is commonly used diagnostically to evoke cortical responses, while repetitive TMS (rTMS) delivers repeated pulses intended to produce longer‑lasting changes in cortical activity for therapeutic purposes. Variants include theta‑burst stimulation (TBS) — patterned bursts of pulses administered at higher within‑burst frequency but lower overall frequency — and navigated TMS (nTMS), which uses neuronavigation to target specific cortical regions for mapping or treatment planning. Evidence for TMS across many non‑behavioral indications is limited by small, heterogeneous studies and short follow-up.

Definitions and Modality Descriptions

rTMS / Theta‑burst / Navigated TMS — modality descriptions

rTMSRepetitive transcranial magnetic stimulation: repeated magnetic pulses delivered noninvasively to induce lasting changes in cortical activity; used therapeutically in trials for pain, epilepsy, headaches, Parkinson disease, stroke, and tinnitus.

Theta‑burst stimulation (TBS)Patterned form of rTMS using short bursts (typically 3–5 pulses per burst) at higher within‑burst frequency with an interburst interval that yields a lower overall frequency; studied in intermittent (iTBS) and continuous (cTBS) protocols and in accelerated/MRI‑guided variants.

Navigated TMS (nTMS)Neuronavigation‑guided TMS that targets precise anatomical cortical locations for functional mapping and preoperative planning (motor/language mapping); investigated as a diagnostic/planning tool rather than a therapeutic modality.

rTMS — definition and study parameter variability

DefinitionRepetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique that delivers repeated magnetic pulses to modulate cortical excitability beyond the stimulation period.

Policy Revision History

2026-02-01title_and_content_revisionLatest

Title changed from 'Transcranial Magnetic Stimulation Supporting Information'; Description of Services, Clinical Evidence, and References sections updated; previous policy version 2026T0536V archived.

OpenPayer

Transcranial Magnetic Stimulation for Treating Physical Health Conditions