UnitedHealthcare TMS Coverage Update Prior Auth

Coverage Criteria and Evidence Summary

Not medically necessary for medical (non‑behavioral) conditions

Covered when ALL of the following are met

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

Applies to listed conditions and other non‑behavioral conditions

Epilepsy evidence summary

Evidence from randomized trials and systematic reviews for rTMS in drug-resistant epilepsy:

Epilepsy evidence: Cochrane and systematic reviews include small randomized trials (total ~230-241 individuals); most trials show no significant seizure reduction versus control though two trials reported large within-group seizure reductions; evidence certainty is low to very low.

Adverse events uncommon but increased seizure frequency occurred in a small number; heterogeneity of techniques and outcomes prevented pooled efficacy conclusions.

Headache / Migraine evidence summary

Systematic reviews and meta-analyses provide mixed and heterogeneous evidence for rTMS in migraine:

Migraine evidence: Multiple meta-analyses and systematic reviews report some trials showing reduced migraine frequency or monthly migraine days with specific HF-rTMS targets (for example HF-rTMS over C3 or left DLPFC), but heterogeneity in stimulation parameters, small sample sizes, short follow-up, and inconsistent outcomes limit conclusions; NICE advises use only with special arrangements or research.

Network meta-analysis favored HF-rTMS over C3 for monthly migraine days but overall evidence quality and consistency are limited.

Parkinson disease evidence summary

rTMS has been evaluated for motor and some nonmotor symptoms in PD in multiple RCTs and meta-analyses:

PD motor outcomes: Systematic reviews and randomized trials (including 16–24 trials across analyses) generally show small-to-moderate short-term motor benefits from rTMS, with HF-rTMS targeting M1 and multisession protocols often associated with larger effects; evidence is limited by heterogeneity, small samples, and variable protocols and optimal parameters are not defined.

Some trials report improvements in freezing of gait, walking time, and UPDRS motor scores but consistency and long-term effects are uncertain.

Pain (neuropathic and chronic pain) evidence summary

rTMS has mixed evidence for various pain conditions:

Neuropathic pain and chronic pain: Randomized trials and meta-analyses report modest short-term reductions in pain intensity for some neuropathic pain etiologies (for example SCI, DPN) with HF-rTMS over M1 or left DLPFC; pooled results are inconsistent and some high-quality meta-analyses found only small effects below minimally important clinical difference thresholds.

Heterogeneity in targets, frequencies, number of sessions, and small sample sizes limit generalizability; larger, well-designed trials with longer follow-up are needed.

Coverage-intent clinical indications and evidence summary

Evidence-based summaries and meta-analyses show heterogeneous results across indications; coverage with criteria may be appropriate where higher-quality evidence exists.

Tinnitus (chronic): rTMS demonstrated statistically significant improvements in Tinnitus Handicap Inventory (THI) scores at 1 week, 1 month, and 6 months across multiple randomized trials and meta-analyses, though study heterogeneity and need for multicenter validation remain.evidence: multiple RCTs/meta-analyses

Consider documentation of diagnosis, prior standard therapies, validated tinnitus scales (THI/TQ), and treatment parameters if coverage considered.

Poststroke motor function: Systematic reviews and network meta-analyses report that LF-rTMS and HF-rTMS may improve certain lower-extremity and motor outcomes after stroke, but evidence is heterogeneous and protocol-dependent.evidence: multiple RCTs and meta-analyses

Coverage contingent on documented functional deficits, standardized outcome measures (for example Fugl-Meyer), and integration with rehabilitation.

Evidence summaries relevant to coverage

Evidence-based stances and summaries relevant to coverage decisions

nTMS for preoperative motor mapping: nTMS may aid preoperative motor mapping and pooled observational analyses report reduced postoperative permanent motor deficits (OR ~0.54) and increased gross total resection (OR ~2.32), but evidence is limited to observational studies and high-quality RCTs are needed.observational meta-analysis evidence

When used, document indication, mapping method, findings, and how mapping influenced surgical planning.

nTMS language mapping shows variable sensitivity and specificity compared with intraoperative direct cortical stimulation (ranges reported widely); data are heterogeneous and additional validation is required.variable sensitivity/specificity

nTMS may be informative but is not a definitive replacement for DCS.

Theta-burst stimulation (TBS): Accelerated, repetitive, and MRI-guided TBS lack sufficient clinical and safety data to conclude benefit; available randomized trials are small and inconclusive.

Unproven/Not Medically Necessary - additions

Policy revisions updated which TMS services are considered unproven or not medically necessary and added specific protocols and indications.

Unproven/Not Medically Necessary Additions: Transcranial magnetic stimulation (TMS) for treating traumatic brain injury (TBI) and theta-burst stimulation including accelerated and/or MRI-guided protocols were added to the list of unproven and not medically necessary services.

From policy revision effective 06/01/2026; see policy history for coding changes.

This policy explicitly excludes the use of transcranial magnetic stimulation (TMS) for behavioral disorders from its medical (non‑behavioral) coverage determinations and directs behavioral TMS to the separate Optum Behavioral Clinical Policy. For all listed 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 — TMS is considered unproven and not medically necessary due to insufficient evidence of efficacy as summarized in the clinical evidence review.

Professional bodies have highlighted evidence limitations for rTMS in headache disorders. The European Headache Federation states that application of noninvasive rTMS for chronic headaches is "not yet evidence based" because of the paucity of high‑quality controlled data. Similarly, the NICE guideline on TMS for treating and preventing migraine concludes evidence is limited in quantity and quality and recommends TMS for migraine only with special arrangements for clinical governance, consent, audit, or research rather than as routine care.

The American Academy of Otolaryngology–Head and Neck Surgery (AAO‑HNS) clinical practice guideline for tinnitus recommends that clinicians should not recommend TMS for patients with persistent, bothersome tinnitus, reflecting a guideline‑level recommendation against routine clinical use of TMS for this indication.

The AAO‑HNS guidance asserting clinicians should not recommend TMS for persistent, bothersome tinnitus is noted in the evidence base and informs the policy stance. In addition, patterned TMS approaches such as theta‑burst stimulation (including accelerated and MRI‑guided protocols) have been reviewed and are specifically identified as lacking sufficient clinical and safety data; as a result, these theta‑burst protocols have been added to the policy list of unproven and not medically necessary services.

This policy notes updates to the coding section and specifically indicates that several TMS‑related CPT codes (including 0858T, 0889T, 0890T, 0891T, 0892T, 90867, 90868, and 90869) are not listed on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid; providers should consult the Idaho Medicaid Provider Handbook for details on non‑covered and excluded services.

Examples of medical, non‑behavioral conditions for which TMS is considered unproven and not medically necessary include: Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches (including migraine), Parkinson disease, stroke, tinnitus, and traumatic brain injury. The policy lists these conditions to clarify that routine TMS use for these medical indications is not supported by sufficient evidence.

For indications where the evidence is low‑certainty or inconsistent, routine clinical use is not supported. For example, randomized trials and systematic reviews for drug‑resistant epilepsy are small and heterogeneous with low to very low certainty, and multiple headache/migraine reviews report heterogeneous results and limited quality — leading the policy to conclude that routine rTMS use for such indications is not warranted outside research or special governance arrangements.

Pooled analyses of noninvasive brain stimulation (NIBS) for post‑spinal cord injury neuropathic pain — which included rTMS, tDCS, and CES — demonstrated no significant effect on neuropathic pain reduction versus sham in the available trials; the review concluded these findings do not support routine use of NIBS for post‑SCI neuropathic pain and larger studies are needed.

The policy explicitly adds theta‑burst stimulation (TBS) — including accelerated and MRI‑guided variants — to the list of services considered unproven and not medically necessary, stating that studies demonstrating the clinical use and safety of these accelerated, repetitive MRI‑guided TBS protocols are lacking and therefore benefit cannot be concluded.

Randomized trial evidence for TMS in traumatic brain injury (TBI) is limited and inconclusive; a small randomized, placebo‑controlled study reported no significant cognitive benefit for rTMS in chronic diffuse axonal injury. Based on this limited evidence, the policy lists TMS for TBI (and theta‑burst protocols) among services considered unproven and not medically necessary.

Procedure Codes and Coding Notes

Applicable / referenced CPT 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.

No specific CPT/ICD codes in this document portionmixed

No codes listed

Policy-noted CPT codes and changesCPT

0858T	Listed in policy notation (not on State of Idaho Medicaid Fee Schedule)
0889T	Newly added CPT code (policy notes addition)
0890T	Newly added CPT code (policy notes addition)
0891T	Newly added CPT code (policy notes addition)
0892T	Newly added CPT code (policy notes addition)
90867	TMS-related CPT code (not on State of Idaho Medicaid Fee Schedule per policy)
90868	TMS-related CPT code (not on State of Idaho Medicaid Fee Schedule per policy)
90869	TMS-related CPT code (not on State of Idaho Medicaid Fee Schedule per policy)
64999	Previously listed miscellaneous CPT code — removed from policy

Policy coding changes and fee-schedule notationsCPT

0889T	Added CPT code 0889T
0890T	Added CPT code 0890T
0891T	Added CPT code 0891T
0892T	Added CPT code 0892T
0858T	Not on State of Idaho Medicaid Fee Schedule (notation added)
90867	Not on State of Idaho Medicaid Fee Schedule (notation added)
90868	Not on State of Idaho Medicaid Fee Schedule (notation added)
90869	Not on State of Idaho Medicaid Fee Schedule (notation added)
64999	Removed CPT code 64999

Minimal clinically important difference — pain thresholds

Minimal clinically important difference (pain)Often defined as ≥15% change or ≥1.5 points on a 0–10 NRS; pooled single-dose HF‑rTMS effects (0.40 points or ~7% reduction) do not meet this threshold.

Fibromyalgia pooled changePooled RCTs showed mean pain reductions of −1.2 points immediately and −0.7 points at 1 week–1 month, both below the 1.5‑point MCID.

Cochrane short‑term pain effectMeta-analysis of 27 rTMS studies (655 individuals) showed a 0.40‑point reduction (7%), judged below MCID.

nTMS reported effect sizes (pooled observational data)

Reduced new permanent motor deficits (nTMS)Pooled observational studies reported an odds ratio of 0.54 for postoperative new permanent motor deficits with nTMS motor mapping.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization and Code Reference

Prior authorization is required and subject to Idaho-state rules and the member's benefit contract; the codes listed in this policy are provided for reference and do not guarantee coverage. For Idaho Medicaid members, codes marked with an asterisk (*) are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered. Verify plan/federal/state/contractual requirements before billing.

Prior authorization required when coverage is requested for transcranial magnetic stimulation (TMS) procedures for non‑behavioral indications in Idaho-member benefits.
Codes listed in the Applicable Codes section are for reference only; listing does not imply coverage or reimbursement.
CPT codes added 06/01/2026: 0889T, 0890T, 0891T, 0892T (verify prior authorization and coverage per state/contract rules).
Codes not on the Idaho Medicaid Fee Schedule (may not be covered): 0858T, 0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869.

Prior Authorization

Prior Authorization Recommended for Headache Indications

Prior authorization is recommended for use of rTMS for headache indications (including migraine). Evidence is limited and NICE recommends use only with special arrangements for clinical governance, consent, audit, or research; document trials of guideline‑recommended medical management and other conservative therapies prior to approval.

Background and Context

Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that delivers magnetic pulses to the scalp which induce small electrical currents in the cerebral cortex. Single‑pulse TMS is primarily used diagnostically and for cortical mapping, while therapeutic approaches — including repetitive TMS (rTMS), theta‑burst stimulation (TBS), and navigated TMS (nTMS) — aim to modulate cortical excitability over repeated sessions but remain investigational for many medical (non‑behavioral) conditions due to limitations such as small sample sizes, heterogeneous stimulation parameters, and short follow‑up in the clinical literature.

Definitions and Modality Descriptions

Descriptions and modalities of TMS

rTMS (repetitive TMS)Repetitive delivery of magnetic pulses to induce changes in cortical activity that persist beyond stimulation; studied therapeutically for pain, epilepsy, headaches, Parkinson disease, stroke, and tinnitus.

Theta‑burst stimulation (TBS)A patterned form of rTMS delivering short bursts (3–5 pulses) at high intraburst frequency with a theta‑frequency interburst pattern; includes accelerated and MRI‑guided variants under study.

Navigated TMS (nTMS)Uses neuronavigation (often MRI‑based) to stimulate precise anatomical cortical locations for diagnostic mapping and preoperative planning.

High‑frequency rTMS (HF‑rTMS) — definition and ranges

Definition of HF‑rTMSHigh‑frequency rTMS refers to stimulation at higher pulse rates (commonly ~10 Hz and other frequencies within ~5–20 Hz used in studies) often applied to M1 or left DLPFC for motor and pain indications.

OpenPayer

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

Coverage Criteria and Evidence Summary

Procedure Codes and Coding Notes

Prior Authorization, Documentation, and Billing Guidance

Background and Context

Definitions and Modality Descriptions