ModifiedUnitedHealthcarePolicy CS124KS.03

Transcranial Magnetic Stimulation for Treating Physical Health Conditions (for Kansas Only)

Defines UnitedHealthcare Community Plan coverage stance for transcranial magnetic stimulation (TMS) when used to treat physical (non‑behavioral) medical conditions in Kansas members; behavioral TMS is handled under a separate Optum behavioral policy.

Policy Summary

PayerUnitedHealthcare

PolicyTranscranial Magnetic Stimulation for Treating Physical Health Conditions (for Kansas Only)

Policy CodePolicy CS124KS.03

Change TypeTitle and supporting information updated

Effective DateMar 1, 2026

Next Review Date

Key ActionVerify and submit indication-specific prior authorization with trial-level evidence, stimulation parameters, and documentation of prior standard therapy failures when applicable.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Transcranial Magnetic Stimulation (for Kansas Only) - Supporting Information' to the current title; supporting information sections were updated to reflect the most current information.

Kansasstate-specific application

multipleunproven physical conditions

8procedure codes referenced

insufficientoverall efficacy

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OR 0.54reduced motor deficit risk (nTMS)

OR 2.32increased GTR rate (nTMS)

Coverage Criteria and Evidence Summary

Not medically necessary / Unproven indications

Transcranial magnetic stimulation is considered unproven and not medically necessary for the following physical (non‑behavioral) conditions due to insufficient evidence of efficacy:

Unproven conditions list: TMS for treating all medical (non‑behavioral) conditions including but not limited to: Alzheimer disease; chronic neuropathic pain; dystonia; epilepsy; headaches; Parkinson disease; stroke; tinnitus; traumatic brain injury; navigated transcranial magnetic stimulation for treatment planning or diagnosing motor neuron diseases or neurological disorders; theta‑burst stimulation including accelerated and/or MRI‑guided protocols.

Listed as unproven/not medically necessary due to insufficient evidence

Epilepsy

Summary of evidence findings for rTMS in epilepsy:

Epilepsy evidence summary: rTMS is generally safe but evidence for clinically meaningful seizure reduction is lacking; a Cochrane review of seven trials (N=230) found only two trials with significant seizure reduction while five trials showed no difference versus control, and the overall quality of evidence was judged low.

Technique variability and inconsistent outcomes limit conclusions; reductions in epileptiform discharges have been observed but clinical seizure benefit remains unproven.

Headaches / Migraine

Summary of evidence findings for rTMS in migraine and other primary headache disorders:

Migraine evidence summary: Multiple RCTs and meta-analyses report promising but heterogeneous results for rTMS in migraine: some trials and pooled analyses (e.g., Zhong et al., Cheng et al.) found reductions in migraine frequency or monthly migraine days for specific high-frequency rTMS targets, but studies vary widely in stimulation site, frequency, pulse dose, sample size, and follow-up; overall evidence is preliminary and inconclusive.

NICE recommends TMS for migraine only with special arrangements for clinical governance/consent/audit or research; European Headache Federation states current evidence is not yet sufficient.

Parkinson disease (PD)

Summary of evidence findings for rTMS in Parkinson disease (PD) motor and nonmotor symptoms:

PD evidence summary: Multiple RCTs and meta-analyses report modest, short-term motor improvements with rTMS; pooled analyses suggest HF-rTMS (particularly multisession, higher total pulses and M1 targets) shows larger effects on motor outcomes, while evidence for cognition, gait, dyskinesia, and long-term benefit is mixed or limited.

Heterogeneous study designs, small samples, and lack of standardized protocols limit translation into routine clinical practice; additional high-quality studies are needed to define optimal parameters.

Neuropathic and chronic pain

Summary of evidence findings for rTMS in neuropathic and chronic pain conditions:

Neuropathic pain evidence summary: Some RCTs and meta-analyses report modest short-term analgesic effects of HF-rTMS over M1 or left DLPFC for specific neuropathic conditions (e.g., SCI, diabetic peripheral neuropathy), and multisession protocols tend to yield larger, more sustained effects than single sessions; however, pooled analyses across conditions are inconsistent and certainty ranges from very low to low.

Observed effect sizes are generally small and often below minimal clinically important differences; larger, standardized trials with longer follow-up are required.

Coverage considerations by indication

Evidence summaries and guideline positions indicate variable effects by indication and target; these differences should inform coverage considerations:

Neuromodulation overall: Across indications, trial results are heterogeneous: some meta-analyses report small short-term benefits (e.g., chronic pain short-term effect equating to ~7% pain reduction), while other pooled analyses show no significant effect for certain conditions (e.g., NIBS after SCI); overall certainty is low to very low, arguing against routine coverage for many indications absent stronger evidence.evidence insufficient for routine coverage

Multiple sources call for larger, standardized trials.

Tinnitus: Several meta-analyses report improvements in Tinnitus Handicap Inventory scores at 1 week to 6 months after rTMS in RCTs, but specialty guideline (AAO-HNS) recommends clinicians should not recommend TMS for persistent, bothersome tinnitus.mixed evidence; specialty guideline unfavorable

Positive trial-level findings exist but guideline recommendation is against routine recommendation.

Evidence summaries and implications

Clinical evidence statements from guidelines and systematic reviews relevant to TMS, nTMS, and TBS include:

AAN - Restless Legs: The AAN states rTMS is possibly effective (level C) for primary moderate to severe restless legs syndrome based on one class II study.

Limited evidence supports possible effectiveness for this specific indication.

AAN - Tics/Tourette: AAN guidelines indicate insufficient evidence to determine benefit of various rTMS and theta-burst interventions for tics, with confidence downgraded due to imprecision.

Evidence insufficient; no definitive efficacy.

nTMS for surgical planning: Systematic reviews report nTMS can accurately map motor and language cortices and observational meta-analyses associate nTMS motor mapping with reduced postoperative permanent motor deficits (OR 0.54) and increased gross total resection rate (OR 2.32), but high-level RCT evidence is lacking and standardized protocols are needed.

Suggests potential benefit for surgical planning but calls for more robust randomized data.

Behavioral disorders are outside the scope of this state policy. For TMS used to treat behavioral or psychiatric conditions, refer clinicians to the separate Optum Behavioral Clinical Policy titled Transcranial Magnetic Stimulation available on Optum Provider Express; this policy only addresses TMS for physical (non‑behavioral) medical conditions.

The evidence base for many neuromodulation indications is limited by small sample sizes, heterogeneous stimulation protocols, short follow‑up, and inconsistent outcome reporting. As a result, routine use of rTMS or other noninvasive brain stimulation techniques for numerous physical indications (outside of controlled research or specialized governance arrangements) is not supported by current data.

The American Academy of Otolaryngology–Head and Neck Surgery Guideline Development Panel states that clinicians should not recommend TMS for patients with persistent, bothersome tinnitus.

Accelerated and MRI‑guided forms of theta‑burst stimulation have insufficient clinical evidence. Studies demonstrating the clinical use and safety of accelerated, repetitive, MRI‑guided theta‑burst stimulation are lacking, and it is not possible to conclude these protocols provide a beneficial health outcome.

This policy assesses transcranial magnetic stimulation for physical (non‑behavioral) medical conditions, including but not limited to Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches (including migraine), Parkinson disease, stroke, tinnitus, and traumatic brain injury. Behavioral and psychiatric TMS indications are excluded and addressed under the separate Optum Behavioral Clinical Policy.

For epilepsy, available trials report that rTMS appears safe but evidence is inconsistent and technique variability prevents definitive conclusions. A Cochrane review of seven trials (total N=230) found only two studies with statistically significant seizure reductions and judged the overall quality of evidence low; therefore clinical seizure reduction with rTMS remains unestablished and rTMS for seizure control is considered investigational outside research settings.

Current data do not support routine use of rTMS for neuropathic pain after spinal cord injury or for cognitive deficits following traumatic brain injury. Systematic reviews of NIBS after spinal cord injury found no significant effect on neuropathic pain, and small randomized trials in chronic TBI have not demonstrated cognitive benefit; larger, methodologically rigorous studies are needed before these indications can be considered effective.

Navigated TMS (nTMS) for diagnostic evaluation or treatment planning is not yet supported by sufficient evidence. Existing studies are limited by small sample sizes, heterogeneous populations, and weak designs, so nTMS cannot be concluded to reliably improve diagnostic accuracy or clinical treatment planning at this time.

The policy references standard procedure codes used for TMS services and advanced protocols, including CPT codes such as 0858T, 0889T, 0890T, 0891T, 0892T, 90867, 90868, and 90869, which should be used for prior authorization and claims submissions as applicable.

Procedure and Regulatory Codes

Referenced TMS procedure codesCPT

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.

Regulatory-cleared devices discussedmixed

No codes listed

Coding referencedmixed

not specified

The document portion provided does not list explicit CPT, HCPCS, or ICD-10 codes.

FDA product codes (informational)mixed

GWF, HAW, IKN, OBP, OCI, OKP

FDA product codes referenced for TMS devices.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Providers must verify and obtain any plan-specific prior authorization before initiating TMS therapy. UnitedHealthcare may require use of InterQual criteria or an approved UnitedHealthcare clinical policy for authorization decisions. Prior authorization alone does not guarantee coverage — confirm member-specific benefit plan language and applicable federal/state/contractual requirements.

Prior authorization may require submission of InterQual or UnitedHealthcare criteria references.
Authorization requirements may vary by plan and state; check member benefits prior to scheduling.

Documentation Required

Required Clinical Documentation and Stimulation Parameters

Documentation (clinical evidence and stimulation parameters) is required to support medical necessity determinations. Submit indication-specific trial-level evidence including prior treatment history, baseline symptom measures, detailed stimulation parameters, and treatment outcomes.

Background and Technique Description

Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that uses time‑varying magnetic fields to induce electrical currents in targeted cortical areas. Single‑pulse TMS is commonly used for functional cortical mapping, while repetitive TMS (rTMS) delivers repeated pulse trains intended to produce longer‑lasting modulatory effects. Protocols vary by frequency, target site (for example, primary motor cortex or dorsolateral prefrontal cortex), and modality (including theta‑burst and navigated or MRI‑guided approaches). The evidence for applying TMS to many physical neurologic conditions is limited by small sample sizes, heterogeneous protocols, and brief follow‑up periods.

Definitions and Abbreviations

Theta-burst stimulation — definition and note

DefinitionTheta-burst stimulation (TBS) is a patterned form of rTMS in which short bursts of 3–5 pulses are delivered at a higher within-burst frequency with an interburst interval that produces a lower overall frequency, intended to induce longer-lasting changes in cortical excitability.

Common protocolsIncludes intermittent TBS (iTBS) and continuous TBS (cTBS); iTBS is typically excitatory and cTBS inhibitory in physiologic studies.

Accelerated/MRI-guided variantsAccelerated and MRI-guided TBS protocols are being studied (e.g., fMRI‑connectivity guided iTBS), but studies demonstrating clinical use and safety of accelerated, repetitive, MRI-guided TBS are lacking.

Clinical contextTBS is investigated for cognitive and psychiatric indications and as an alternative rTMS dosing strategy to shorten treatment duration and potentially improve adherence.

Navigated transcranial magnetic stimulation definition

Policy Summary

PayerUnitedHealthcare

PolicyTranscranial Magnetic Stimulation for Treating Physical Health Conditions (for Kansas Only)

Policy CodePolicy CS124KS.03

Change TypeTitle and supporting information updated

Effective DateMar 1, 2026

Next Review Date

Key ActionVerify and submit indication-specific prior authorization with trial-level evidence, stimulation parameters, and documentation of prior standard therapy failures when applicable.

SourceLink

On This Page

Stroke motor recovery: Systematic reviews and network meta-analyses suggest LF- and HF-rTMS may improve some motor outcomes (e.g., Fugl-Meyer, upper-extremity motor tests) in poststroke recovery, but heterogeneity and small trials limit firm conclusions.evidence preliminary; potential coverage in context of trials or select cases

Confirmatory high-quality RCTs needed.

Poststroke neurogenic bladder: A single RCT (n=100) showed LF-rTMS improved urodynamic and patient-reported bladder outcomes versus sham, indicating promising but limited evidence.promising but limited evidence

Consideration for coverage may require confirmatory data.

Traumatic brain injury cognitive deficits: Small randomized trials (e.g., chronic diffuse axonal injury) have not demonstrated significant cognitive benefit of rTMS versus sham; evidence is insufficient to support use.not supported

Larger trials required.

Guideline positions: Guidelines vary by indication: AAN finds rTMS possibly effective (level C) for moderate-to-severe primary restless legs syndrome based on limited data and indicates insufficient evidence for tics; NICE restricts routine use of TMS for migraine to special arrangements for governance or research.follow specialty guideline guidance

Guidelines should be considered when making coverage decisions.

Theta-burst stimulation (TBS): Accelerated, repetitive, MRI-guided theta-burst stimulation lacks sufficient studies to conclude clinical benefit or safety; small and heterogeneous trials produce inconclusive results.

Evidence preliminary and inconclusive; FDA listings are informational only.

Document prior failed therapies (medication names, doses, durations, and intolerance or inadequate response).
Provide baseline and follow-up outcome measures (e.g., PHQ-9 for depression, headache days per month for migraine, pain scales for neuropathic pain).
Include stimulation protocol details: target site, frequency (Hz), intensity (% motor threshold), pulses per session, number of sessions, and any neuronavigation or MRI-guided targeting used.

Step Therapy

Conservative Therapy Prerequisites and Step Therapy Expectations

Conservative therapy prerequisites and step therapy expectations: prior conservative or standard therapies should be documented and typically must have failed or been not tolerated before TMS is considered. Lack of documented trials of standard therapies may result in denial.

For behavioral indications, document trials of guideline-recommended pharmacologic and psychotherapeutic treatments with dates and outcomes.
For pain or headache indications, document appropriate medical, rehabilitation, or preventive therapy trials and response.
If step therapy protocols are specified by the member's plan, follow those protocols; this document does not define plan-specific step therapy sequences.

Denial Risk

Investigational/Unproven Indications and Coverage Risk

Requests for TMS to treat medical (non‑behavioral) conditions listed as unproven: TMS for medical indications (e.g., Alzheimer disease, epilepsy, chronic neuropathic pain, stroke, tinnitus, traumatic brain injury, Parkinson disease, headaches/migraine) is considered investigational or not medically necessary in many cases due to insufficient or inconsistent evidence. Providers should expect investigational/non‑covered determinations unless covered by specific plan language or clinical trial enrollment.

Special arrangements (governance, consent, audit, research) — for migraine, NICE recommends use only with such arrangements; absence may affect coverage decisions.
Requests for novel protocols (e.g., theta-burst, accelerated, MRI‑guided) are frequently considered investigational given limited evidence and heterogeneous protocols.

Denial Risk

Insufficient Evidence May Trigger Denial

Insufficient evidence may trigger denial: heterogeneous study designs, small sample sizes, inconsistent stimulation protocols, and outcomes that do not meet minimal clinically important differences are common limitations. When evidence is low or uncertain for the requested indication or protocol, expect denial unless compelling, well-documented rationale and supporting data are submitted.

Examples of higher-risk requests: single small RCTs without replication, accelerated/theta-burst protocols without supportive comparative evidence, and uses outside commonly studied targets/sessions.
Provide trial-level outcome data and rationale when requesting coverage for less-established protocols to mitigate denial risk.

Billing Rule

Coding and Billing Caveat

Provider Coding and Billing Guidance: Inclusion of codes in this policy is for reference only and does not guarantee coverage or payment. Verify benefit coverage and billing rules with the member's plan.

Common CPT/Treatment codes referenced include 90867, 90868, 90869, 0858T, 0889T–0892T and other device/procedure codes; use codes per the payer's billing guidance.
Listing of a code does not imply reimbursement — confirm prior authorization and claim submission requirements.

Note

Coverage Decision Guidance and Regulatory Note

Coverage Decision Guidance: In the event of a conflict between this policy and federal, state, or contractual benefit requirements, the federal/state/contractual requirements govern. UnitedHealthcare may modify policies as needed. FDA clearance/approval of devices is informational and is not by itself a basis for coverage.

Check member-specific benefits and applicable laws prior to initiating therapy.
If InterQual criteria apply, they will be used as the primary medical/surgical criteria for authorization decisions.

Note

Provider Actions (Checklist)

Provider Actions (operational checklist): gather and submit required documentation at prior authorization including indication, prior treatments and outcomes, baseline measures, detailed stimulation protocol, and planned outcome assessments; verify plan-specific prior authorization and step therapy requirements; and document governance or research enrollment when required (e.g., migraine programs per NICE guidance).

Attach supporting clinical notes, objective outcome scales, trial summaries, and device/protocol descriptions.
Confirm whether the member's plan requires enrollment in a registry, special consent, or audit arrangements for certain indications (e.g., migraine).
Contact UnitedHealthcare/provider portal to confirm prior authorization requirements and to submit documentation.

DefinitionNavigated transcranial magnetic stimulation (nTMS) combines TMS with neuronavigation to stimulate and localize cortical areas at precise anatomical locations for mapping or treatment planning.

Primary uses studiedPreoperative motor and language mapping and diagnostic stimulation to induce measurable functional responses for surgical planning.

Evidence caveatData are insufficient to conclude that nTMS is effective for treatment planning or diagnostic evaluation due to limited studies, small sample sizes, and heterogeneous populations; larger RCTs are needed.

rTMS definition — repetitive transcranial magnetic stimulation

DefinitionRepetitive transcranial magnetic stimulation (rTMS) delivers repeated magnetic pulses to cortical targets to produce effects that can last beyond the stimulation period; used investigationally for motor, pain, seizure, and other indications.

Mechanism and deliveryMagnetic pulses induce an electrical current in cortex without anesthesia; single-pulse TMS maps function while rTMS aims to modulate cortical excitability for therapeutic effect.

Evidence summarySafety is generally acceptable across studies, but efficacy evidence is heterogeneous and indication-dependent; many trials are small with variable protocols, limiting firm conclusions for many physical (nonbehavioral) indications.

HF-rTMS / LF-rTMS — definition and frequency ranges

DefinitionsHigh-frequency rTMS (HF-rTMS) generally refers to stimulation frequencies above 1 Hz (commonly 5–20 Hz in cited studies) and is often associated with facilitatory effects; low-frequency rTMS (LF-rTMS) typically refers to 1 Hz or lower and is often associated with inhibitory effects.

Typical frequency rangesHF-rTMS commonly studied at 5–20 Hz (e.g., 10 Hz); LF-rTMS commonly at 1 Hz.

Clinical implicationEffects differ by frequency and cortical target (e.g., HF over M1 showed greater benefit for PD motor outcomes in pooled analyses); parameter selection influences outcomes and evidence quality varies by protocol.

nTMS — navigated TMS definition and evidence caveats

DefinitionnTMS (navigated TMS) is TMS guided by neuronavigation systems to precisely target cortical regions for mapping motor and language areas and to inform surgical planning.

Mapping strengthsSystematic reviews report nTMS can accurately map motor and language cortices and has been used to assist preoperative planning and to predict motor deficit risk.

Evidence caveatsDespite promising observational data (e.g., associations with reduced permanent motor deficits and increased GTR in meta-analyses), high-level RCT evidence and standardized protocols are lacking, limiting definitive diagnostic or planning claims.

HF-rTMS / LF-rTMS (additional) — protocol frequency details and target sites

Protocol detailsHF-rTMS protocols commonly use frequencies in the 5–20 Hz range (for example, 10 Hz is frequently studied); LF-rTMS protocols commonly use 1 Hz stimulation.

Target sitesCommon cortical targets studied include primary motor cortex (M1), dorsolateral prefrontal cortex (DLPFC), and parietal/occipital sites (e.g., C3) depending on indication such as PD, pain, or migraine.

Dose and session considerationsFor some indications (e.g., PD), multisession HF-rTMS with higher total pulse counts (e.g., 18,000–20,000 total pulses over treatment course) was associated with larger motor improvements in pooled analyses.

nTMS (additional) — neuronavigation mapping uses and limitations

Uses for neuronavigationnTMS is used to map motor and language cortices preoperatively, to localize functional areas relative to lesions, and to support individualized surgical planning.

Observed benefitsMeta-analyses of observational studies report associations between nTMS motor mapping and reduced permanent motor deficits (OR 0.54) and increased gross total resection rates (OR 2.32), suggesting potential surgical advantages.

LimitationsEvidence is primarily from observational studies with variable methods; standardized MEP protocols and larger RCTs are needed before routine diagnostic/planning use can be endorsed.

TBS — theta-burst stimulation definitions (intermittent/continuous)

TBS variantsTheta-burst stimulation includes intermittent TBS (iTBS) and continuous TBS (cTBS); iTBS is generally excitatory and cTBS inhibitory in experimental paradigms.

Intermittent TBS (iTBS)iTBS delivers bursts in a pattern designed to produce net excitatory effects and has been explored for memory/cognitive enhancement and psychiatric indications.

Continuous TBS (cTBS)cTBS applies bursts in a continuous train intended to produce net inhibitory effects; comparative efficacy versus sham and other rTMS protocols remains under investigation and evidence is presently inconclusive.