Transcranial Magnetic Stimulation (for Louisiana Only)

Coverage summary and scope

This Louisiana-only medical policy (Policy Number CS124LA.L) is effective July 1, 2025 and is Part 1 of 3. It describes UnitedHealthcare's scope and coverage stance for transcranial magnetic stimulation (TMS) technologies for neurologic and neuropsychiatric indications; the overall coverage stance is mixed with a number of uses explicitly listed as unproven and not medically necessary due to insufficient evidence. The policy lists specific CPT codes and notes state-specific fee schedule limitations for certain codes.

The policy covers high-level descriptions of TMS modalities and evidence summaries for conditions such as Alzheimer disease, epilepsy, headaches, Parkinson disease and others, but it excludes behavioral disorders from this document — behavioral-disorder TMS is governed separately by the Optum Behavioral Clinical Policy titled "Transcranial Magnetic Stimulation" available at Optum Provider Express. The policy also notes that some newly added CPT codes (0889T–0892T) are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by Louisiana Medicaid.

Key stats and dates

Explicitly listed unproven medical indications9

CPT/HCPCS codes referenced8

CPT codes added4

CPT code removed1

Overall Evidence Certaintylow

Medical necessity and unproven indications

Unproven and Not Medically Necessary Indications

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

TMS for listed medical conditions: Transcranial magnetic stimulation (TMS) for treating all medical (i.e., non-behavioral) conditions including but not limited to: Alzheimer's disease; Chronic neuropathic pain; Dystonia; Epilepsy; Headaches; Parkinson's disease; Stroke; Tinnitus; Traumatic brain injury (TBI).
nTMS: Navigated transcranial magnetic stimulation (nTMS) for treatment planning or for diagnosing motor neuron diseases or neurological disorders.
Theta-burst stimulation including accelerated and/or MRI guided protocols.

Applicable codes and notes

Referenced CPT / HCPCS codes (for reference only)CPT

0858T	Externally applied transcranial magnetic stimulation with concomitant measurement of evoked cortical potentials with automated report.
0889T	Personalized target development for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation derived from a structural and resting-state functional MRI, including data preparation and transmission, generation of the target, motor threshold-starting location, neuronavigation files and target report, review and interpretation.
0890T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including target assessment, initial motor threshold determination, neuronavigation, delivery and management, initial treatment day.
0891T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, subsequent treatment day.
0892T	Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, subsequent motor threshold redetermination with delivery and management, per treatment day.
90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management.
90868	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session.
90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management.

Added CPT codes (noted in policy history)CPT

0889T	Added to Applicable Codes per 07/01/2025 revision
0890T	Added to Applicable Codes per 07/01/2025 revision
0891T	Added to Applicable Codes per 07/01/2025 revision
0892T	Added to Applicable Codes per 07/01/2025 revision

Removed CPT codesCPT

64999

Removed from Applicable Codes per 07/01/2025 revision

State fee schedule notemixed

*	Codes labeled with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program.

State-specific coverage notemixed

0889T/0890T/0891T/0892T

Not on the State of Louisiana Medicaid Fee Schedule; may not be covered by Louisiana Medicaid Program

Actions, documentation, and billing guidance

Prior Authorization

Prior authorization likely required for rTMS/nTMS interventions

Given the mixed evidence and limited high-quality data for therapeutic rTMS and navigated TMS (nTMS), payer-level prior authorization is likely required for these interventions. Providers should be prepared to submit clinical justification and relevant supporting literature when requesting approval for rTMS or nTMS services.

Denial Risk

Denial risk for routine use in conditions with insufficient evidence

Claims for routine use of TMS/nTMS in indications with insufficient or low-quality evidence (for example TBI cognitive deficits or routine navigated TMS for diagnostic evaluation) are at elevated risk of denial.

Background, evidence summaries, and definitions

Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation technique in which magnetic pulses are used to activate cortical neurons. Single‑pulse TMS is used diagnostically (eg, to elicit motor evoked potentials) and repetitive TMS (rTMS) is used to induce changes in brain activity that can outlast the stimulation period. Protocols vary by frequency, target site (eg, M1, DLPFC), depth (including deep TMS), and session number.

Navigated TMS (nTMS) uses neuronavigation to deliver TMS to precise anatomical targets and is being investigated for preoperative motor and language mapping and treatment planning; available evidence is largely observational and randomized data are limited.

Theta‑burst stimulation (TBS) is a patterned form of rTMS delivering short bursts of pulses (eg, 3–5 pulses per burst) with interburst intervals that produce an overall lower frequency; accelerated and MRI‑guided intermittent TBS approaches are under investigation. The policy states that nTMS and TBS (including accelerated and/or MRI‑guided protocols) are considered investigational/unproven for the described treatment planning and therapeutic indications.

Behavioral and psychiatric disorder indications are not addressed in this Louisiana policy and are deferred to the Optum Behavioral Clinical Policy for Transcranial Magnetic Stimulation.

Evidence topic	Summary
Alzheimer disease	Multiple small RCTs and meta-analyses report mixed cognitive improvements versus sham; several meta-analyses found significant short-term and longer-lasting SMDs (examples: Yan 2023 short-term SMD 0.91; Lin 2019 SMD 0.60; Zhang 2021 SMD 0.83) but trials are heterogeneous, small, and NICE recommends offering only in RCTs; further large trials needed.
Epilepsy (Cochrane)	Cochrane reviews (Walton 2021; Chen 2016) found low to very low‑certainty evidence: some trials show seizure reduction or reduced epileptiform discharges, but overall efficacy not established due to heterogeneity and small studies; safety generally acceptable but evidence insufficient.
Headaches	Systematic reviews and meta-analyses report heterogeneous results: some studies show reduced migraine frequency/intensity (e.g., Zhong 2022, Cheng 2022 network meta-analysis showing HF‑rTMS C3 MD -8.70 days), but overall evidence limited in quantity/quality; NICE (2014) recommends use only with governance/research.
Parkinson disease	Multiple meta-analyses report modest short-term motor improvement with rTMS (pooled MDs: 3.4 short-term and 4.1 at ~6 weeks on UPDRS per Wagle Shukla 2016; other analyses show benefits for gait/FOG and selected measures) but studies are heterogeneous and no standardized protocol defined; more research needed.
Pain meta-analyses (Saleh 2022; O'Connell 2018)	Mixed evidence: Saleh 2022 (SCI neuropathic pain) reported MD -0.81 (95% CI -1.45 to -0.17) favoring rTMS; Cochrane/O'Connell 2018 (27 studies, 655 participants) found a small short-term effect equivalent to 0.40‑point reduction on 0–10 scale (~7%), below MCID; overall evidence low quality and heterogeneous.
Tinnitus meta-analyses	Several meta-analyses (Liang 2020; Yin 2021; Soleimani 2016) report significant improvements in THI/TQ scores at timepoints from 1 week to 6 months (examples: Liang reported THI MDs ~ -7.9 at 1 week, -8.52 at 1 month, -6.53 at 6 months) but study heterogeneity and need for larger trials noted; AAO‑HNSF guideline (2014) recommended against TMS for persistent bothersome tinnitus.
nTMS tumor mapping outcomes (Raffa 2019)	Systematic review/meta-analysis (Raffa 2019) of observational studies found nTMS motor mapping associated with reduced new permanent motor deficits (OR 0.54) and increased gross total resection rate (OR 2.32); evidence from observational series supportive but randomized high‑level trials lacking.
nTMS tumor mapping outcomes (Sollmann 2018)	Sollmann et al. 2018 reported outcomes for 60 patients using preoperative nTMS and nTMS‑based DTI tractography: 28.3% had residual tumor, 8.3% new permanent language deficits, KPS unchanged; study lacked a control group and randomized data.
Diffusion MRI-guided TBS (Chen 2022)	Chen et al. 2022 studied diffusion MRI‑guided theta‑burst stimulation in MCI and found improved associative memory performance and increased hippocampal resting‑state functional connectivity; limited by small sample size and variability; accelerated/MRI‑guided TBS protocols lack sufficient clinical evidence and safety data.

Glossary — key terms used in this policy:

rTMS (Repetitive transcranial magnetic stimulation): repeated magnetic pulses delivered to a cortical target to induce longer‑lasting changes in brain activity.

nTMS (Navigated transcranial magnetic stimulation): TMS guided by neuronavigation to stimulate precise anatomical locations; investigated for diagnostic mapping and preoperative planning.

FAQs & clinical interpretation

Q: Is rTMS proven effective for chronic pain? A: Systematic reviews and trials report small, often short‑term analgesic effects for certain neuropathic pain conditions — particularly high‑frequency stimulation targeting M1 — but the overall evidence quality is low and many pooled effects are below commonly used minimal clinically important difference thresholds; larger, well‑designed trials are needed.

Q: Can navigated TMS replace intraoperative direct cortical stimulation (DCS)? A: nTMS correlates with intraoperative DCS mapping and observational series associate preoperative nTMS mapping with improved surgical metrics (for example, reduced new permanent motor deficits and increased gross total resection in pooled observational studies), but randomized, high‑level evidence is lacking and nTMS is not established as a replacement for intraoperative DCS.

Policy revision history

2025-07-01material_changeLatest

Added CPT codes 0889T, 0890T, 0891T, and 0892T to Applicable Codes (effective 07/01/2025).

2025-07-01material_changeLatest

Removed CPT code 64999 from Applicable Codes (effective 07/01/2025).

2025-07-01material_change

General evidence-based conclusions / applicability

Summarized findings from systematic reviews, meta-analyses, RCTs, and guidelines indicating when rTMS/nTMS has evidence of benefit or insufficient evidence:

PD short-term motor improvement: rTMS demonstrated modest short-term motor improvement in Parkinson disease (mean differences ~3.4 to 4.1 points on UPDRS) but studies heterogeneous and no standardized protocol defined.
Pain analgesic effects: High-frequency rTMS of primary motor cortex (M1) shows short-term analgesic effects in certain neuropathic pain conditions; overall evidence heterogeneous and often small sample sizes.
Cochrane pain evidence: Systematic reviews/meta-analyses (e.g., O'Connell 2018 Cochrane) found very low-quality evidence for short-term pain reduction with high-frequency motor cortex rTMS; effects often below minimal clinically important difference.
Stroke mixed evidence: For stroke motor recovery, evidence mixed: some meta-analyses report benefit (HF or LF depending on outcome), but heterogeneity and small trials limit certainty; low-frequency rTMS may improve lower extremity motor function per some network meta-analyses.
Tinnitus results: rTMS for tinnitus: multiple meta-analyses report significant improvements in tinnitus handicap scores at various time points (1 week, 1 month, 6 months) but study heterogeneity and need for larger trials noted.
TBI insufficient: rTMS for traumatic brain injury (TBI): small RCTs show no significant cognitive benefit; evidence insufficient.
AAN RLS: AAN guideline: rTMS possibly effective (level C) for primary moderate to severe restless legs syndrome based on one Class II study; insufficient evidence for tics/Tourette interventions.
AAO-HNS tinnitus guidance: AAO-HNS guideline: clinicians should not recommend TMS for persistent bothersome tinnitus (2014).
nTMS mapping correlation: nTMS (navigated TMS) for preoperative motor and language mapping: multiple systematic reviews/meta-analyses report that nTMS mapping correlates with intraoperative direct cortical stimulation (DCS) and is associated with reduced postoperative motor deficits and increased gross total resection in observational studies, but high-level randomized evidence lacking.
nTMS limitations: Due to limited, heterogeneous studies and small sample sizes, navigated TMS is considered to have insufficient data to conclude effectiveness for treatment planning/diagnostic evaluation; further larger RCTs needed.