ModifiedUnitedHealthcarePolicy CS124KY.08

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

Policy governing the medical necessity and coverage stance for transcranial magnetic stimulation (TMS) and related techniques when used to treat non-behavioral/physical health conditions in Kentucky members of UnitedHealthcare Community Plan.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS124KY.08

Change TypeTitle and content revision (administrative and content update)

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionPrior authorization should require submission of supporting clinical trial‑level evidence or documentation of enrollment in an approved research/clinical governance program for migraine rTMS.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Transcranial Magnetic Stimulation (for Kentucky Only)' and supporting sections (Description of Services, Clinical Evidence, References) updated to reflect current information; previous policy version archived (CS124KY.07).

multiple conditionsNot medically necessary list

0858T, 0889T-0892T, 90867-90869Procedure codes listed

Kentucky onlyState-specific

OR 0.54 / 2.32nTMS benefit signal

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Coverage Criteria and Evidence Summaries

inv-01: Not Medically Necessary

The following uses are unproven and considered not medically necessary due to insufficient evidence of efficacy:

Not Medically Necessary - Physical Conditions: Transcranial magnetic stimulation for treating all medical (non-behavioral) conditions including but not limited to Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches, Parkinson disease, stroke, tinnitus, and traumatic brain injury is considered unproven and not medically necessary.

Policy applies to Kentucky members.

Not Medically Necessary - Techniques: Navigated transcranial magnetic stimulation for treatment planning or diagnosing motor neuron diseases or neurological disorders, and theta-burst stimulation including accelerated and/or MRI-guided protocols are considered unproven and not medically necessary.

For behavioral disorders, refer to Optum Behavioral Clinical Policies.

inv-02: Epilepsy (drug-resistant)

Epilepsy — Evidence summary

Epilepsy evidence: Repetitive TMS (rTMS) is generally safe, but evidence for reducing seizure frequency in drug-resistant epilepsy is lacking; trials are small and heterogeneous with only 2 of 7 RCTs showing significant seizure reductions and overall low certainty for primary outcomes.

Cochrane review (Chen et al. 2016) included 7 trials (n=230) and judged primary outcome evidence low.

inv-03: Migraine and other primary headaches

Headaches / Migraine — Evidence summary

Migraine evidence and limitations: Systematic reviews and meta-analyses report some positive signals for HF-rTMS (reduced monthly migraine days and attack frequency) and other neurostimulation methods, but study heterogeneity (stimulation site, frequency, pulses, sessions), small sample sizes, short follow-up, inconsistent results across trials, and limited quantity/quality of evidence limit conclusions.

NICE recommends TMS only with special arrangements for governance, consent, and audit or research; European Headache Federation considers evidence insufficient for routine use.

inv-04: Parkinson disease (motor symptoms, freezing of gait, cognition)

Parkinson disease — Evidence summary

PD motor and nonmotor outcomes: Multiple RCTs and meta-analyses report modest, short-term motor improvements with rTMS; HF-rTMS targeting M1, bilateral M1 stimulation, multisession protocols, and higher total pulses are associated with greater effects, while cognitive effects are inconsistent and optimal parameters are not established.

Heterogeneity, small study sizes, and variable protocols limit certainty and preclude definitive treatment recommendations.

inv-05: Neuropathic and chronic pain

Neuropathic and chronic pain — Evidence summary

Pain indications: rTMS targeting M1 or left DLPFC shows transient pain reductions in some neuropathic pain conditions (including spinal cord injury, diabetic peripheral neuropathy, and chronic neuropathic pain), but results are inconsistent across reviews and indications; effects are often short-lived, heterogeneous, and of low or very-low certainty depending on single vs multiple sessions.

Some meta-analyses report small but statistically significant reductions; other pooled analyses (post-SCI) found no overall effect, so routine use is not supported.

inv-06: Coverage conclusions by indication

Coverage stance and limiting criteria based on cited evidence:

Neuropathic pain (general / SCI): rTMS, tDCS, and CES: pooled analyses showed no significant overall effect on neuropathic pain after spinal cord injury; routine use of noninvasive brain stimulation for post-SCI neuropathic pain is not supported.

Evidence includes pooled meta-analyses showing no significant pain reduction after SCI.

Chronic neuropathic pain (M1 rTMS): High-frequency rTMS of the primary motor cortex (M1) can produce statistically significant but transient reductions in chronic neuropathic pain versus sham; certainty ranges from very-low (single session) to low (multiple sessions), and effect sizes often do not meet minimal clinically important difference.

Multiple RCTs and systematic reviews report heterogeneity in stimulation parameters and short duration of benefit.

Central neuropathic pain (ACC/PSI dTMS): Deep rTMS targeting the anterior cingulate cortex (ACC) or posterior superior insula (PSI) was not superior to sham for primary pain outcomes in a 12-week RCT, though some secondary outcomes (heat pain threshold, anxiety) showed change.

inv-07: Evidence conclusions and coverage-relevant summaries

Evidence summaries and conclusions present in this section:

nTMS for preoperative motor and language mapping: Observational studies and systematic reviews/meta-analyses suggest nTMS motor mapping is associated with reduced postoperative permanent motor deficits and increased gross total resection, but definitive high-level randomized controlled trials are lacking; use may aid surgical planning.observational data and meta-analyses show OR 0.54 for permanent motor deficits and OR 2.32 for GTR

Further well-designed RCTs are needed to establish causal benefit and standardized protocols for motor evoked potentials (MEPs).

nTMS diagnostic/other uses: Data are insufficient to conclude that nTMS is effective for treatment planning and/or diagnostic evaluation across heterogeneous indications; larger RCTs required.insufficient evidence

Evidence limited by small sample sizes and weak study designs.

Theta-burst stimulation (TBS):

This policy excludes coverage for behavioral and psychiatric disorders. For behavioral indications, providers should refer to the Optum Behavioral Clinical Policies rather than this UnitedHealthcare Kentucky TMS policy.

Guidance from external bodies cautions that evidence for noninvasive rTMS in chronic headaches and migraine prevention/treatment is limited. The NICE guideline (2014) recommends TMS for migraine only with special arrangements for clinical governance, consent and audit or research, and the European Headache Federation states that noninvasive rTMS for chronic headaches is not yet evidence based because controlled data are sparse.

Available systematic reviews and randomized trials do not support routine use of noninvasive brain stimulation (NIBS) for neuropathic pain after spinal cord injury; pooled analyses found no significant pain reduction and recommended further study. Similarly, deep TMS targeting the anterior cingulate cortex or posterior superior insula did not differ from sham for primary pain relief in a 12‑week RCT, so certain dTMS approaches for central neuropathic pain are not supported.

Image‑guided navigated TMS (nTMS) and accelerated or MRI‑guided theta‑burst stimulation protocols lack sufficient high‑quality evidence to conclude clinical effectiveness for many diagnostic or therapeutic indications. Current data are limited by small samples, heterogeneous designs, and absence of definitive RCTs; therefore these techniques are considered unproven in non‑behavioral indications.

This policy applies to the listed non‑behavioral physical conditions when TMS (including navigated or theta‑burst protocols) is proposed for treatment: Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches/migraine, Parkinson disease, stroke, tinnitus, traumatic brain injury, and other medical neurologic conditions. Uses for behavioral disorders are excluded and covered under Optum Behavioral Clinical Policies.

For several indications the body of evidence is graded as low or very‑low certainty. Examples include drug‑resistant epilepsy, where small heterogeneous trials produced inconsistent effects on seizure frequency and overall low certainty (Cochrane review), and neuropathic pain indications where pooled analyses report small or no effects and low to very‑low certainty depending on single versus multiple session data.

Meta‑analyses and systematic reviews indicate that single‑session high‑frequency (HF) rTMS and low‑frequency (LF) rTMS, and rTMS applied to the dorsolateral prefrontal cortex (DLPFC) for chronic pain, generally produce small, transient reductions in pain that do not meet commonly used minimal clinically important difference thresholds; these findings are judged to be of very‑low to low certainty.

Current evidence does not establish clinical benefit for navigated TMS when used for diagnostic or non‑mapping treatment planning, nor for accelerated or MRI‑guided theta‑burst stimulation. Studies to date are small, heterogeneous, and insufficient to support routine clinical use; further well‑designed RCTs and standardized protocols are needed.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required for rTMS in Chronic Pain

Prior authorization is required for repetitive transcranial magnetic stimulation (rTMS) when requested for chronic pain indications. Prior authorization requests should include clinical rationale, prior treatment history, and proposed treatment plan for review against medical necessity criteria.

Applicable to rTMS for chronic neuropathic or other chronic pain conditions where transient benefit has been reported.
Authorization decisions will consider evidence of limited and heterogeneous benefit and may require additional documentation or specialist consultation.

Documentation Required

Governance and Research Protocols Required for Migraine rTMS

For use of TMS to treat or prevent migraine, require documentation of clinical governance or an approved research protocol. Prior authorization for migraine rTMS should include the governance framework, informed consent processes, audit plan, and any registry or research oversight information.

Procedure and Billing Codes

Applicable Procedure Codesmixed

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.

Background and Scope

Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation technique. Single‑pulse TMS is used primarily for functional cortical mapping, while repetitive TMS (rTMS) delivers repeated magnetic pulses intended to modulate cortical activity beyond the immediate stimulation period. Protocols vary by frequency, target (for example, primary motor cortex or dorsolateral prefrontal cortex), depth (including deep TMS), and patterned forms such as theta‑burst stimulation; evidence for many physical neurologic indications remains limited by small sample sizes, short follow‑up, and heterogeneous methods.

Definitions and Terminology

inv-36: rTMS — definition of repetitive transcranial magnetic stimulation

DefinitionRepetitive transcranial magnetic stimulation (rTMS): repeated magnetic pulses delivered to the cortex intended to induce changes in brain activity that persist beyond the stimulation period; used experimentally and clinically to modulate cortical excitability and treat various neurologic conditions.

MechanismMagnetic field pulses pass through hair, skin, and skull to induce small electrical currents in brain tissue, activating neurons and influencing neurotransmitter release (e.g., serotonin, norepinephrine, dopamine).

Clinical use contextSingle‑pulse TMS is used for functional mapping; rTMS protocols (various frequencies, targets, and depths) are under investigation for conditions such as pain, epilepsy, headaches, Parkinson disease, stroke, and tinnitus.

inv-37: Theta-burst stimulation — definition and delivery notes

DefinitionTheta‑burst stimulation (TBS): a patterned form of rTMS in which short bursts (typically 3–5 pulses per burst) are delivered at a high intraburst frequency with a specific interburst interval that yields a lower overall frequency.

Policy Revision History

2026-03-01revisionLatest

Title changed from 'Transcranial Magnetic Stimulation (for Kentucky Only)' and supporting sections (Description of Services, Clinical Evidence, References) updated; previous policy version CS124KY.07 archived.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS124KY.08

Change TypeTitle and content revision (administrative and content update)

Effective DateMarch 1, 2026

Next Review DateN/A

SourceLink

On This Page

Randomized three-arm trial (Galhardoni et al.) found no significant pain relief versus sham.

Chronic pain / fibromyalgia (rTMS): Meta-analyses show small short-term pain reductions with HF-rTMS of motor cortex that often fall below minimal clinically important differences; guideline recommendations are weak or inconclusive and further high-quality trials are needed.

Cochrane and other reviews report small effect sizes (e.g., 0.4-point change on 0–10 scale) with heterogeneity.

Stroke motor recovery: rTMS (LF or HF) may improve upper or lower extremity motor outcomes in some trials; network meta-analysis found LF-rTMS superior to sham for some lower extremity outcomes, but heterogeneity and variable protocols limit strong recommendations.

RCTs and network meta-analyses report mixed results and call for further high-quality studies.

Spasticity after stroke: Uncontrolled pre-post studies suggest improvements in spasticity measures, but RCT data do not consistently demonstrate significant treatment effects; evidence is limited.

Meta-analysis of RCTs failed to show significant effect on wrist MAS.

Tinnitus: Multiple meta-analyses (including up to 29 RCTs) found rTMS improved Tinnitus Handicap Inventory (THI) scores at short- and longer-term follow-up in pooled analyses, suggesting efficacy in some studies; however, heterogeneity and methodological variability persist and some guidelines refrain from recommending routine clinical use.

Meta-analyses report significant MDs in THI at 1 week, 1 month, and 6 months in pooled data.

Traumatic brain injury (cognitive outcomes): Small RCTs in chronic diffuse axonal injury found no significant cognitive benefit from rTMS; evidence insufficient to support routine use for cognitive recovery after TBI.

Single-center RCT (n=30) showed no between-group differences on neuropsychological tests.

Restless legs syndrome and tics: Evidence is limited to a few class II/III studies; AAN guidelines rate rTMS possibly effective for moderate to severe restless legs syndrome (level C) but insufficient for tics/Tourette syndrome.

Recommendations are based on limited-quality studies.

Navigated TMS (nTMS): Insufficient data to conclude nTMS is effective for treatment planning or diagnostic evaluation across indications; observational meta-analyses suggest potential benefits for preoperative motor mapping (reduced permanent motor deficits and increased gross total resection) but randomized trials are lacking.

Observational pooled analyses report OR 0.54 for permanent motor deficits and OR 2.32 for GTR; higher-level RCT evidence is needed.

Studies demonstrating clinical use and safety of accelerated, repetitive, MRI-guided theta-burst stimulation are lacking; available small RCTs and pilot studies (e.g., for OCD, MCI) yield inconclusive or preliminary results and require further research.

insufficient high-quality evidence

Limited sample sizes, heterogeneity, and need for protocol refinement noted.

Follow NICE guidance: TMS for migraine should be used only with special arrangements for clinical governance, consent, audit, or research.
Submit protocol or description of oversight (institutional review board, trial registration, or service audit arrangement) with prior authorization request.

Denial Risk

Denial Risk for TMS for Listed Physical Conditions and Unproven Protocols

TMS therapies for the listed non-behavioral physical conditions are considered unproven and may be denied as not medically necessary. Providers should be aware of the high risk of coverage denial when requesting TMS for these indications without robust supporting evidence.

Examples of physical conditions with denial risk: Alzheimer disease; chronic neuropathic pain (routine use); dystonia; epilepsy; Parkinson disease; stroke; tinnitus; traumatic brain injury; headaches (preventive migraine uses require governance); others as listed in policy.
Navigated TMS for diagnostic or treatment planning and theta-burst/accelerated or MRI‑guided theta-burst protocols are considered experimental/unproven and are at risk for denial.

Billing Rule

Coding and Documentation Requirements

Document the procedure and relevant diagnosis codes, clinical indications, treatment parameters, and outcome measures in the medical record and include them with any prior authorization request. Listing of procedure codes in this policy is for reference only and does not guarantee coverage or reimbursement.

Providers should include CPT/HCPCS and ICD-10 codes on submissions and ensure documentation supports medical necessity.
Inclusion of a code in policy does not imply coverage; benefit coverage is governed by federal, state, or contractual requirements.

Documentation Required

Governance, Protocol, and Audit Documentation

When clinical use is requested outside well-established indications, provide standardized protocols and governance documentation. For migraine and other investigational uses, include details on protocol, monitoring plans, adverse event reporting, and planned outcome reporting.

Provide protocol title, objectives, inclusion/exclusion criteria, stimulation parameters, schedule, and safety monitoring.
Indicate whether the treatment is part of a registered trial or a formally audited clinical service.

Documentation Required

Required Supportive Outcome Documentation

Prior authorization and ongoing clinical documentation should include objective outcome measures appropriate to the treated condition to support continued therapy and evaluation of benefit.

Recommended outcome measures by condition: Pain — Numeric Rating Scale (NRS) or validated pain inventories; Tinnitus — Tinnitus Handicap Inventory (THI) or Tinnitus Questionnaire (TQ); Stroke/Recovery — Fugl‑Meyer assessment; Urologic indications — urodynamic measures where appropriate.
Document baseline scores and serial post-treatment measurements to demonstrate response or lack of benefit.

Note

Criteria Source for Authorization and Coverage Decisions

Coverage decisions will reference InterQual® criteria as the primary source. When InterQual does not have applicable criteria, UnitedHealthcare medical policy, coverage determination guidelines, and utilization review guidelines (including applicable state or federal contractual requirements) will be used to determine coverage.

Always verify applicable federal, state, or contractual requirements; those requirements govern in case of conflict.
Policy reviewers may require additional documentation or adhere to more restrictive local contract terms.

Step Therapy

Conservative Therapy Prerequisite and Stepwise Use

Require failure, intolerance, or contraindication to guideline‑recommended conservative therapies before considering rTMS for certain indications (for example, epilepsy or chronic neuropathic pain). Prior authorization should document prior trials, duration, and responses to conventional therapies.

Document trials of standard pharmacologic and nonpharmacologic therapies, reasons for discontinuation, and objective measures of inadequate response.
Stepwise use after guideline-recommended therapies is expected before approval for investigational or limited-use rTMS.

Delivery variantsMay be delivered as intermittent (iTBS) or continuous (cTBS) protocols and can be administered in accelerated schedules (multiple sessions per day) to shorten overall treatment duration.

Emerging techniques and evidenceFunctional MRI–guided and MRI/diffusion‑guided connectivity‑based TBS approaches are under study (e.g., for treatment‑resistant depression, MCI, OCD), but clinical safety and efficacy of accelerated/MRI‑guided TBS remain insufficiently established.

inv-38: Navigated TMS — definition (neuronavigation-guided) for mapping or treatment planning

DefinitionNavigated transcranial magnetic stimulation (nTMS): TMS performed with neuronavigation/image guidance to target precise anatomical cortical locations for mapping or treatment planning.

Primary applicationsUsed for preoperative motor and language cortical mapping to localize functionally essential areas and inform surgical strategy and risk assessment.

Evidence summaryObservational studies and systematic reviews suggest nTMS mapping is informative and associated with improved surgical planning metrics (e.g., increased gross total resection, reduced permanent motor deficits), but larger RCTs and standardized protocols are needed to confirm clinical benefit.

inv-39: HF-rTMS / LF-rTMS — definitions of high- and low-frequency rTMS

HF‑rTMSHigh‑frequency repetitive TMS (HF‑rTMS): stimulation delivered at higher frequencies (commonly >1 Hz, typically in the 5–20 Hz range) and often associated with facilitation/increasing cortical excitability; used in many positive PD and migraine studies.

LF‑rTMSLow‑frequency repetitive TMS (LF‑rTMS): stimulation delivered at lower frequencies (commonly ~1 Hz) and generally associated with reductions in cortical excitability; used in some stroke and pain protocols.

Clinical implicationsHF and LF protocols have differing neurophysiologic effects and are selected based on intended facilitation or inhibition of targeted cortical regions (e.g., M1 for motor/pain, DLPFC for mood/migraine).

inv-40: M1 target — primary motor cortex as stimulation target

DefinitionM1 target: the primary motor cortex (M1), a common stimulation target for rTMS when treating neuropathic pain and motor symptoms in Parkinson disease or for motor mapping purposes.

RationaleStimulation of M1 can modulate motor excitability and has been used both therapeutically (pain reduction, motor function improvement) and diagnostically (motor mapping with single‑pulse TMS).

Protocol notesHF‑rTMS over M1 (multisession, higher total pulses) is associated with larger effect sizes for motor improvements in PD; parameters vary across studies and are not standardized.

inv-41: HF-rTMS / LF-rTMS (frequency detail) — frequencies commonly used for HF and LF rTMS

HF frequency rangeHigh‑frequency rTMS is commonly delivered in the range of about 5–20 Hz (studies often report 10 Hz as a common HF setting).

LF frequency exampleLow‑frequency rTMS is commonly delivered at approximately 1 Hz or similar low‑frequency settings used to reduce cortical excitability.

Parameter effectsHF (5–20 Hz) tends to increase motor excitability and has been linked to short‑term motor and migraine benefits; LF (~1 Hz) tends to decrease excitability and is used where inhibitory effects are desired (e.g., some stroke protocols).

inv-42: navigated TMS (nTMS) — image-guided TMS for localization; evidence insufficient for many treatment uses

DefinitionImage‑guided navigated TMS (nTMS): the combination of TMS with real‑time neuronavigation using individual imaging to localize cortical targets precisely for mapping or treatment planning.

Intended usesDesigned to localize cortical targets for preoperative mapping (motor and language) and to inform surgical approaches or therapeutic targeting.

Evidence limitationsCurrent evidence is limited by small studies, heterogeneous designs, and lack of large RCTs; data are insufficient to conclude effectiveness for many diagnostic or treatment‑planning uses.

inv-43: nTMS (detailed) — combining TMS with neuronavigation for preoperative motor and language mapping

Technique descriptionnTMS combines transcranial magnetic stimulation with neuronavigation and individual imaging to map cortical motor and language functions preoperatively.

Clinical roleUsed to assist surgical planning by identifying motor and language cortical representations, predicting postoperative deficits, and potentially guiding extent of resection.

Evidence and gapsSystematic reviews and meta‑analyses show promising associations (e.g., improved gross total resection rates and reduced postoperative motor deficits), but standardized MEP protocols and high‑quality randomized trials are lacking to establish definitive clinical benefit.

inv-44: Theta-burst stimulation (TBS) — patterned TMS form including accelerated and MRI-guided variants

DefinitionTheta‑burst stimulation (TBS) is a patterned rTMS protocol delivering short high‑frequency bursts with defined interburst intervals to produce longer‑lasting neuromodulatory effects; includes intermittent (iTBS) and continuous (cTBS) forms.

Variants under studyAccelerated TBS (multiple daily sessions) and MRI‑guided/functional connectivity‑guided TBS (targeting based on individual imaging) are being investigated to improve efficacy and shorten treatment courses.

Evidence statusClinical safety and effectiveness data for accelerated and MRI‑guided TBS protocols are limited; existing small trials show preliminary or inconclusive results and further research is needed.