ModifiedUnitedHealthcarePolicy CS124NE.P

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

This Nebraska-only UnitedHealthcare medical policy governs coverage and medical necessity determinations for transcranial magnetic stimulation (TMS) used to treat medical (non-behavioral) conditions and related technologies for members covered by UnitedHealthcare in Nebraska.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS124NE.P

Change TypeRevised title and evidence sections

Effective Date03/01/2026

Next Review DateN/A

Key ActionVerify member plan coverage and obtain prior authorization using the listed procedure codes when requesting TMS for medical indications.

SourceLink

POLICY UPDATE CHANGES

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

Title changed from 'Transcranial Magnetic Stimulation (for Nebraska Only) Supporting Information' to current title.

Title changed and description of services, clinical evidence, and references updated to reflect current information.

NebraskaApplies only to

multipleUnproven conditions

listedProcedure codes

heterogeneous

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Evidence limitations

19Migraine RCTs (network MA)

Coverage Criteria and Evidence Summaries

Not Medically Necessary / Unproven Indications

Covered status for physical health conditions:

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

Applies to listed examples such as Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches, Parkinson disease, stroke, tinnitus, and traumatic brain injury; navigated TMS for diagnostic or treatment planning and theta-burst/accelerated/MRI-guided protocols are also considered unproven.

Epilepsy — Evidence

Epilepsy — evidence summary

Cochrane review findings: Eight randomized trials (241 individuals) of rTMS for drug-resistant epilepsy had heterogeneous designs; two trials showed large seizure reductions while six did not show significant changes; adverse events were uncommon but seizures sometimes increased; overall certainty of evidence rated low to very low.

Sources: Walton et al. 2021 and Chen et al. 2016

Migraine / Headache — Evidence

Headaches / Migraine — evidence summary

RCTs and meta-analyses: Multiple RCTs and meta-analyses report mixed findings: some analyses (including network meta-analyses) identify reductions in monthly migraine days with specific HF-rTMS targets (e.g., C3) and some trials show reduced headache frequency or intensity, but heterogeneity in stimulation parameters, small sample sizes, and inconsistent outcomes limit definitive conclusions.

NICE recommends use only with special arrangements due to limited quantity/quality of evidence; European Headache Federation considers noninvasive rTMS not yet evidence based for chronic headaches.

Parkinson Disease — Evidence

Parkinson disease — evidence summary

rTMS for motor and gait outcomes: Multiple RCTs and meta-analyses report short-term motor improvements with rTMS in Parkinson disease; HF-rTMS over M1, multisession and higher pulse counts, and bilateral stimulation are associated with larger effects, while cognition effects are inconsistent and protocols are heterogeneous.

Some analyses report improvements in freezing of gait, walking time, Timed Up and Go, and UPDRS motor scores; further high-quality studies are needed to define optimal parameters.

Pain — Evidence

Pain — evidence summary

Neuropathic and chronic pain: Trials and systematic reviews of rTMS for neuropathic and chronic pain yield mixed results: some RCTs and meta-analyses report short-term analgesic effects (not always statistically significant) and improvements in pain-related disability for certain targets (M1, left DLPFC), while pooled analyses for post–spinal cord injury neuropathic pain did not show consistent benefit; overall evidence is limited by small trials, short follow-up, heterogeneity, and effects often below minimal clinically important differences.e.g., many trials report <15% reduction or <1.5 points on 0–10 NRS

Certainty of evidence ranges very low to low; routine use for many pain indications is not supported without further evidence or research enrollment.

Coverage stance by condition

Coverage considerations should reflect where evidence shows benefit versus insufficient evidence:

Tinnitus (chronic): rTMS demonstrated statistically significant improvements in Tinnitus Handicap Inventory scores in multiple meta-analyses (29 RCTs, 1,228 individuals), with effects observed at 1 week, 1 month, and up to 6 months; consider coverage with criteria for chronic, refractory tinnitus after prior standard therapies and documentation of THI scores.THI improvements reported in pooled analyses

AAO-HNS guideline, however, recommends against routine recommendation of TMS for persistent, bothersome tinnitus; guideline weight should inform coverage decisions.

Neuropathic pain and chronic pain: rTMS targeting M1 (HF) shows short-term analgesic effects and modest midterm/long-term reductions in some meta-analyses, but heterogeneity and often subthreshold clinical effect sizes suggest investigational status or coverage with evidence development for many pain indications.pain reduction varied; many pooled estimates below minimal clinically important difference

Evidence certainty low; consider conservative therapy first and requirement for prior therapies before authorization.

Evidence summaries and coverage considerations by indication/technique

Coverage considerations and evidence summaries by indication/technique:

Society guidance for tinnitus: The AAO-HNS guideline indicates clinicians should not recommend TMS for persistent, bothersome tinnitus, which should inform coverage considerations despite some meta-analyses reporting THI improvements.

AAO-HNS 2014

AAN guidance for restless legs syndrome: AAN states rTMS is possibly effective for primary moderate to severe restless legs syndrome (level C) based on one class II study; consider this limited supportive guidance when evaluating requests.

Winkelman et al., 2016; reaffirmed 2019

AAN guidance for tics/Tourette syndrome: AAN finds insufficient evidence to determine benefit of various TMS interventions for tics; confidence downgraded due to imprecision — consider investigational stance.

Pringsheim et al., 2019

This policy designates transcranial magnetic stimulation (TMS) applications for medical (non–behavioral) conditions as not medically necessary / unproven due to insufficient evidence of efficacy. Examples include but are not limited to Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches, Parkinson disease, stroke, tinnitus, and traumatic brain injury. The policy also considers navigated TMS for treatment planning/diagnosis and theta‑burst (including accelerated and MRI‑guided) protocols unproven for routine clinical use.

Clinical guideline bodies have characterized evidence for TMS in migraine and chronic headache as limited. The NICE guideline (2014) concluded efficacy evidence for treatment and prevention of migraine is limited in quantity and quality and recommended TMS be used only within special arrangements for clinical governance, consent, audit, or research. The European Headache Federation similarly states that noninvasive rTMS for chronic headaches is not yet evidence‑based because of a paucity of controlled data.

The American Academy of Otolaryngology–Head and Neck Surgery (AAO‑HNS) guideline for tinnitus advises clinicians not to recommend TMS for patients with persistent, bothersome tinnitus; this guideline recommendation should be considered when evaluating TMS for chronic tinnitus despite some meta‑analyses reporting positive effects on tinnitus handicap scores.

Specifically, the AAO‑HNS Foundation Guideline Development Panel states that clinicians should not recommend TMS for treatment of persistent, bothersome tinnitus (Tunkel et al., 2014), a position that may inform exclusion or restriction decisions for this indication.

Broadly, TMS interventions for non‑behavioral medical conditions are considered unproven and not medically necessary under this policy. This includes standard repetitive TMS as well as specialized techniques such as navigated TMS and theta‑burst protocols when proposed for medical diagnoses or routine therapeutic use outside of approved behavioral‑health indications.

For neuropathic pain after spinal cord injury, pooled analyses of noninvasive brain stimulation (including rTMS) did not demonstrate a significant pain‑reducing effect versus sham. These findings do not support routine use of NIBS for post‑SCI neuropathic pain and indicate further larger studies are needed.

Across pain and TBI indications, the evidence for noninvasive brain stimulation (NIBS) is heterogeneous and limited. Pooled reviews for neuropathic pain show mixed or no significant effects, and a small randomized trial of rTMS in chronic diffuse axonal injury found no cognitive benefit on neuropsychological outcomes; together, these results support classifying many such medical uses as investigational.

Systematic reviews and small randomized trials have not shown consistent cognitive benefit from rTMS across nonbehavioral indications. Evidence syntheses for neuropathic pain and a single small RCT in traumatic brain injury did not demonstrate reliable improvements on key clinical neuropsychological measures, underscoring limited support for cognitive or broad neurologic benefits from current NIBS protocols.

Applicable Procedure and Device Codes

Applicable/Referenced Procedure CodesCPT | HCPCS

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

No explicit codes in this excerptmixed

No codes listed

FDA device product codes (informational)mixed

GWF, HAW, IKN, OBP, OCI, OKP

FDA product codes referenced for TMS devices (informational only)

Minimal clinically important difference (pain) — example thresholds

Minimal clinically important difference (pain)Example threshold: 15% reduction in pain or ≥1.5-point decrease on a 0–10 numeric rating scale (NRS)

Observed short-term effect in meta-analysisO'Connell et al. (2018) meta-analysis equated pooled rTMS effect to ~7% pain reduction or 0.40-point reduction on 0–10 NRS (below MCID)

Multiple-session effectsMultiple-session rTMS produced larger reductions (weighted mean reductions up to ~22 percentage points for <30 day follow-up) but still frequently below MCID across studies

Fibromyalgia examplePooled trials in fibromyalgia showed mean pain decreases of −1.2 points immediately and −0.7 points at 1 week–1 month — below the 1.5-point MCID

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization and required clinical justification

Prior authorization may be required. Clinical justification must be provided with the request — FDA clearance or device marketing authorization alone is insufficient. Include the specific clinical indication, prior therapies attempted, objective test results when relevant (for example, urodynamic study results for poststroke neurogenic bladder, or documented migraine treatment history), and any relevant imaging or mapping reports for navigated TMS or preoperative planning.

Provide objective supporting data when available (e.g., urodynamics, validated pain or functional scales, migraine frequency diaries).
For navigated TMS (nTMS) or preoperative mapping, include imaging, neuronavigation files, and interpretation reports as applicable.

Note

Verify plan/contract terms and legal requirements

Authorization and coverage decisions depend on the member’s specific plan, contract language, and applicable federal or state mandates. Before submitting an authorization request, verify the plan/contract terms and any statutory requirements that might mandate coverage or impose exclusions.

Background and Scope

Transcranial magnetic stimulation (TMS) is a noninvasive technique that uses focused magnetic pulses to modulate cortical activity. Single‑pulse TMS is commonly used for functional motor mapping, while repetitive TMS (rTMS) delivers trains of pulses intended to induce longer‑lasting changes in brain excitability. Variants include navigated TMS (nTMS) for targeted mapping, and patterned protocols such as theta‑burst stimulation (TBS); although these techniques are employed in research and specialized clinical settings, evidence for many medical (non‑behavioral) applications remains limited.

Definitions and Terminology

Theta-burst stimulation — definition and characteristics

DefinitionTheta-burst stimulation (TBS) is a patterned form of rTMS delivering short bursts (typically 3–5 pulses per burst) at higher intra-burst frequency with specific interburst timing that produces a lower overall stimulation frequency.

Common variantsIncludes intermittent TBS (iTBS, generally excitatory) and continuous TBS (cTBS, generally inhibitory).

Protocol characteristicsCan be delivered in accelerated protocols (multiple sessions/day) and may be guided by MRI-based functional connectivity in investigational approaches.

Clinical statusAccelerated and MRI-guided TBS protocols are under investigation; evidence of clinical benefit and safety is currently insufficient.

Navigated TMS — definition

Definition

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS124NE.P

Change TypeRevised title and evidence sections

Effective Date03/01/2026

Next Review DateN/A

Key ActionVerify member plan coverage and obtain prior authorization using the listed procedure codes when requesting TMS for medical indications.

SourceLink

On This Page

Stroke motor recovery: rTMS trials report mixed improvements in motor function (e.g., Fugl-Meyer gains) with heterogeneous protocols; consider conditional coverage as adjunctive therapy in poststroke rehabilitation when objective baseline and follow-up motor assessments are documented.Fugl-Meyer and other motor outcome improvements reported in some RCTs

Limited sample sizes and variable protocols.

Poststroke neurogenic bladder: A single RCT (n=100) reported significant improvements in urodynamic and patient-reported outcomes with LF-rTMS versus sham; consider coverage in select cases with supporting documentation, recognizing single-center evidence.positive urodynamic and symptom outcomes reported

Replication needed.

TBI cognition: Available randomized data for rTMS in traumatic brain injury did not show cognitive benefit; routine coverage for chronic diffuse axonal injury is not supported.no significant neuropsychological test differences reported

Small trials and heterogeneity.

Restless legs and tics: AAN guidance rates rTMS as possibly effective for primary moderate-to-severe restless legs syndrome (level C, based on one class II study) and finds insufficient evidence for tics/Tourette syndrome; align coverage stance with guideline strength (investigational or limited coverage).AAN level C for restless legs; insufficient for tics

See AAN guidance.

nTMS for preoperative mapping (motor/language): Systematic reviews/meta-analyses suggest nTMS motor mapping is associated with reduced postoperative permanent motor deficits and increased gross total resection rates versus surgery without nTMS, but evidence derives mainly from observational studies and RCTs are needed for confirmation.

Raffa et al. 2019 and related reviews; nTMS evidence mixed and limited by study design heterogeneity.

nTMS limitations: Data for nTMS are limited by small sample sizes, heterogeneous designs, and lack of standardized protocols; additional robust studies and RCTs are needed for broader validation.

Systematic reviews indicate promising but inconclusive findings.

Theta-burst stimulation (including accelerated/MRI-guided): Studies demonstrating clinical use and safety of accelerated, repetitive, MRI-guided theta-burst stimulation are lacking; available RCTs are small and inconclusive, so evidence is insufficient to support routine coverage.

Chen et al. 2022; Rymaszewska et al. 2025 and policy text noting insufficient evidence.

FDA context: FDA has cleared or approved multiple TMS devices (product codes listed) but FDA approval or device listing is informational only and is not by itself a basis for coverage decisions.

Refer to FDA product code listings; coverage requires clinical justification and evidence of medical necessity.

Check member’s benefit document for exclusions or mandated coverage.

If plan terms conflict with this policy, the federal/state/contractual requirements govern and should be cited in the request.

Documentation Required

NICE guidance and governance/research arrangements

NICE concludes TMS for migraine should be used only with special arrangements for clinical governance, consent, audit, or research. Requests for migraine-related TMS may be managed under similar special arrangements (for example, limited coverage tied to enrollment in approved research or a documented governance/audit plan).

When invoking special-arrangement coverage, include the governance plan, consent form template, and audit or research protocol.
Consider requiring enrollment in approved clinical research or registry when coverage is requested for migraine TMS.

Denial Risk

Denial risk when evidence is insufficient

Evidence for many nonstandard indications is limited or of low quality; insufficient high-quality evidence may lead to denial or coverage limitations. FDA approval alone does not establish medical necessity.

Requests for indications listed as unproven/not medically necessary (for example, most medical/non-behavioral conditions listed under Coverage Rationale) are at risk for denial.
Provide rigorous supporting evidence (peer-reviewed RCTs, objective outcome measures) when requesting coverage for emerging or investigational indications.

Documentation Required

Governance, research, and special-arrangement documentation

When coverage is sought under special arrangements or research-related pathways, include documentation of the governance structure, informed consent processes, audit plans, registry enrollment, or research protocol. Documentation should demonstrate oversight and mechanisms to collect outcomes and adverse events.

Attach study or registry protocol, consent language, data collection plan, and local IRB/ethics approvals where applicable.
Identify the responsible clinical lead and data monitoring/audit plan.

Step Therapy

Step therapy and conservative treatment prerequisites

Require documentation of prior conservative or guideline-recommended therapies before approving rTMS for conditions where evidence is limited (for example, migraine). Step therapy or evidence of failure/intolerance to standard treatments may be required.

For migraine: document trials and outcomes of guideline-recommended pharmacologic and nonpharmacologic therapies, and reasons for intolerance or inadequate response.
Specify duration and adherence of prior therapies (e.g., number of preventive medications tried and trial length).

Billing Rule

Pre-checks, coding, and decision-support tools

Use decision-support tools and pre-checks to confirm member benefits and any third-party criteria (for example, InterQual) prior to submitting requests. Verifying plan terms and using available utilization management tools can reduce denials and speed review.

Confirm applicable CPT/HCPCS/diagnosis codes and include them in the authorization request.
Use InterQual or other decision-support criteria if available and applicable to the request.

Denial Risk

Requests for unproven indications

Requests for indications identified in the policy as unproven (for example, transcranial magnetic stimulation for most non-behavioral medical conditions) should include compelling clinical rationale and high-quality evidence; otherwise they are likely to be noncovered.

If submitting for an unproven indication, explain why the case is exceptional and provide any supporting trial data, objective outcome measures, and a proposed plan for monitoring and follow-up.

Navigated transcranial magnetic stimulation (nTMS) is TMS delivered with neuronavigation to target cortical areas at precise anatomical locations for diagnostic mapping or treatment planning.

Primary use under studyUsed for preoperative motor and language mapping to inform surgical planning and reduce diagnostic uncertainty.

Evidence limitationsCurrent data are limited by small studies, heterogeneous designs, and insufficient RCT evidence to confirm clinical utility for treatment planning.

rTMS — definition

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

Variable parametersProtocols vary by frequency (high vs low), coil location (e.g., M1, DLPFC), intensity, number of pulses, and number of sessions across studies.

Clinical applications under studyInvestigated for conditions such as epilepsy, pain, headaches, Parkinson disease, stroke rehabilitation, and tinnitus, with heterogeneous evidence across indications.

HF-rTMS / LF-rTMS — definitions (reference 1)

HF-rTMS definitionHigh-frequency rTMS (HF-rTMS) refers to stimulation at higher rates (commonly ≥5 Hz, examples include 10 Hz) and has been associated in some studies with increased cortical excitability and short-term motor improvements when applied to targets like M1.

LF-rTMS definitionLow-frequency rTMS (LF-rTMS) refers to stimulation at lower rates (commonly ~1 Hz) and is often used to decrease cortical excitability; some studies show LF-rTMS superior to sham for certain stroke motor outcomes.

Dose and target considerationsHF-rTMS over bilateral M1 with higher total pulse counts (e.g., 18,000–20,000 pulses) and multisession protocols yielded larger effects in PD motor outcomes in meta-analysis.

HF-rTMS / LF-rTMS — definitions (reference 2)

HF vs LF effectsNetwork meta-analyses indicate LF-rTMS can improve lower extremity motor function after stroke, while HF-rTMS increases motor-evoked potential amplitudes; HF-rTMS showed greater motor function effects in some PD analyses.

Protocol heterogeneityReported effects depend on stimulation site (e.g., M1 vs DLPFC), frequency, session number, and total pulses; heterogeneity limits definitive conclusions.

Clinical implicationChoice of HF versus LF protocols is indication- and target-specific and should be considered investigational or conditional where evidence remains limited.

Fugl-Meyer Assessment (FMA) — definition

DefinitionThe Fugl–Meyer Assessment (FMA) is a standardized, validated scale used to assess motor function after stroke, commonly used as an outcome measure in rTMS stroke rehabilitation trials.

Domains assessedEvaluates motor performance of upper and lower extremities, balance, sensation, joint range of motion, and pain (motor domain frequently used in rTMS studies).

Use in evidenceNetwork meta-analyses of rTMS in stroke report FMA score improvements as a primary metric for motor function recovery, with LF-rTMS showing superiority to sham in some analyses.

nTMS — navigated transcranial magnetic stimulation definition

DefinitionnTMS (navigated transcranial magnetic stimulation) is TMS integrated with neuronavigation to target cortical regions precisely for mapping or preoperative planning.

Primary applicationsUsed for preoperative motor and language mapping to guide surgical approaches and potentially reduce postoperative deficits.

Evidence caveatAvailable studies are limited by small sample sizes and heterogeneous designs; larger RCTs are needed to confirm clinical impact on treatment planning outcomes.

Theta-burst stimulation (TBS) — definition and variants

Core definitionTheta-burst stimulation (TBS) is a patterned rTMS protocol delivering bursts of pulses at theta frequency (bursts of 3–5 pulses repeated at ~5 Hz) designed to produce longer-lasting neuroplastic effects.

VariantsIncludes intermittent TBS (iTBS, typically excitatory) and continuous TBS (cTBS, typically inhibitory); protocols differ by burst timing and overall session structure.

Emerging approachesAccelerated TBS (multiple daily sessions) and MRI-guided, connectivity-informed TBS are investigational; current evidence is limited and insufficient to confirm clinical benefit or safety for many medical indications.