CurrentUnitedHealthcarePolicy CS124OH.D

Transcranial Magnetic Stimulation (for Ohio Only)

State-specific UnitedHealthcare medical policy (Ohio only) for Transcranial Magnetic Stimulation (TMS) covering adults 18+ with clinical coverage tied to InterQual Procedures: TMS and listing several indications considered unproven/not medically necessary for adults and children. Includes applicable CPT/HCPCS codes and extensive evidence review for multiple conditions.

Policy Summary

PayerUnitedHealthcare

PolicyTranscranial Magnetic Stimulation (for Ohio Only)

Policy CodePolicy CS124OH.D

Change TypeUpdates to coverage and exclusions (material and non-material)

Effective DateJul 1, 2025

Next Review Date

Key ActionFor members age 18 and over, determine medical necessity for TMS by applying the InterQual Procedures: Transcranial Magnetic Stimulation (TMS) clinical coverage criteria and document adherence in the medical record.

POLICY UPDATE CHANGES

Replaced instruction to 'refer to the InterQual CP: Procedures, Transcranial Magnetic Stimulation (TMS) for medical necessity clinical coverage criteria for chronic' with 'refer to the InterQual CP: Procedures, Transcranial Magnetic Stimulation (TMS) for medical necessity clinical coverage criteria'.

Removed 'transcranial magnetic stimulation (TMS) for treating epilepsy, Parkinson's disease, and tinnitus' from previously allowed services and listed them as unproven/not medically necessary.

Added language for Members Under 18 Years of Age indicating multiple conditions (including Alzheimer's disease, chronic neuropathic pain, dystonia, headaches, Parkinson's disease, stroke, tinnitus, TBI, nTMS for treatment planning/diagnosis, theta-burst protocols) are unproven and not medically necessary.

Updated instruction to refer to the Optum Behavioral Clinical Policies for behavioral disorders not addressed in InterQual criteria.

Archived previous policy version CS124OH.C

Coverage Summary

This is a state-specific UnitedHealthcare coverage policy that applies only to members in the state of Ohio. For members 18 years and older, medical necessity for Transcranial Magnetic Stimulation (TMS) is determined by the external InterQual Procedures: Transcranial Magnetic Stimulation (TMS) clinical criteria; behavioral indications not addressed by InterQual are referred to Optum Behavioral Clinical Policies.

The policy uses InterQual as the primary external criteria source for adult medical/surgical coverage determinations and explicitly links coverage decisions and prior authorization processes to those criteria and applicable state or contractual rules.

This policy has a mixed coverage stance: it relies on InterQual for standard adult indications while listing multiple TMS modalities and indications (including theta-burst stimulation, MRI‑guided/accelerated TBS, and navigated TMS (nTMS)) as unproven and not medically necessary for many medical (non‑behavioral) conditions; pediatric (<18) use is specifically excluded for numerous indications due to insufficient evidence.

Key policy facts (brief)

StateOhio

Effective dateJuly 1, 2025

Policy numberCS124OH.D

Primary external criteriaInterQual CP: Procedures, Transcranial Magnetic Stimulation (TMS)

Behavioral cross‑referenceOptum Behavioral Clinical Policies (for behavioral disorders not addressed in InterQual)

Unproven / Not medically necessary indications (headline count)11+ listed unproven/Not Medically Necessary indications (adult + pediatric examples)

Medical-Necessity Criteria

Application / Age-based summary

ALL of the following

Policy applies only to members in the state of Ohio
For members age 18 years and over, medical necessity coverage criteria are determined by InterQual Procedures: Transcranial Magnetic Stimulation (TMS)
For behavioral disorders not addressed in InterQual, refer to Optum Behavioral Clinical Policies

Reference to InterQual and Optum Criteria for Medical Necessity

Refer to the InterQual CP: Procedures, Transcranial Magnetic Stimulation (TMS) for medical necessity clinical coverage criteria

Unproven and Not Medically Necessary Indications

Unproven / Not Medically Necessary (Adults 18+)

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

Transcranial magnetic stimulation (TMS) for treating all medical (i.e., non-behavioral) conditions including but not limited to: Alzheimer's disease

Dystonia

Chronic neuropathic pain

Headaches

Stroke

Evidence Summaries by Indication

Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation technique: single‑pulse TMS is used primarily for exploration and functional mapping, while repetitive TMS (rTMS) is intended to induce longer‑lasting changes in brain activity. Specialized approaches include theta‑burst stimulation (TBS) — patterned bursts producing overall lower frequency stimulation — and navigated TMS (nTMS) which uses neuronavigation for anatomically targeted stimulation.

The evidence base is heterogeneous across modalities and indications: study sizes, protocols, stimulation parameters, and outcomes vary widely, and accelerated or MRI‑guided TBS and many nTMS treatment/diagnostic uses remain understudied and considered investigational.

Evidence summaries by indication

Findings summarized from meta-analyses, randomized controlled trials, and clinical practice guidelines for each indication.

Parkinson disease (PD): Meta-analyses and RCTs demonstrate modest short-term motor improvements with rTMS versus sham; effect sizes modest (0.4-0.6); heterogeneity across studies; limitations include small samples, heterogeneous protocols and populations; no standardized protocol defined

Pain / Neuropathic pain / SCI / DPN / chronic pain / fibromyalgia:

Applicable Procedure and Reference Codes

Applicable Procedure Codes (reference only)mixed

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 including data preparation, transmission, generation of target, 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.

FDA product codes referencedmixed

GWF	Product code family for TMS devices (referenced for informational purposes only)

Provider Actions & Authorization Requirements

Documentation Required

Use InterQual criteria for adult medical necessity determinations

For members age 18 and over, determine medical necessity for TMS by applying the InterQual Procedures: Transcranial Magnetic Stimulation (TMS) clinical coverage criteria and document adherence to those criteria in the medical record.

Applicable CPT codes: 90867, 90868, 90869

Documentation Required

Refer behavioral indications to Optum Behavioral Clinical Policies

For behavioral disorders not addressed in the InterQual criteria, refer to the Optum Behavioral Clinical Policies for coverage determination and document the referenced Optum policy in the medical record when behavioral disorders are the indication.

Definitions

Definitions (terms)

nTMSNavigated transcranial magnetic stimulation — TMS guided by neuronavigation for precise anatomical targeting; studied for preoperative mapping and considered investigational for treatment‑planning/diagnosis

TBSTheta‑burst stimulation — patterned bursts (3–5 pulses per burst) producing overall lower frequency; includes accelerated and MRI‑guided protocols; under investigation

rTMSRepetitive transcranial magnetic stimulation — repeated pulses intended to induce longer‑lasting changes in brain activity (versus single‑pulse mapping)

DLPFCDorsolateral prefrontal cortex — common stimulation target for mood and some pain protocols

M1Primary motor cortex — common stimulation target for motor recovery and neuropathic pain protocols

nTMS (preoperative use)Navigated TMS used for preoperative motor/language mapping and to guide DTI‑based tractography for surgical planning

Revision History

07/01/2025effective_revisionLatest

Effective 07/01/2025: Revised Coverage Rationale — replaced prior InterQual referral wording, revised list of unproven/not medically necessary services (removed prior allowance for TMS for epilepsy, Parkinson's disease, and tinnitus), and updated instruction to refer behavioral disorders not addressed in InterQual to Optum Behavioral Clinical Policies. (Material change)

07/01/2025pediatric_exclusion_addedLatest

Effective 07/01/2025: Added explicit pediatric (members under 18) exclusions — lists multiple conditions (including Alzheimer's disease, chronic neuropathic pain, dystonia, epilepsy, headaches, Parkinson's disease, stroke, tinnitus, TBI, theta-burst protocols, and nTMS for planning/diagnosis) as unproven and not medically necessary. (Material change)

Policy Summary

PayerUnitedHealthcare

PolicyTranscranial Magnetic Stimulation (for Ohio Only)

Policy CodePolicy CS124OH.D

Change TypeUpdates to coverage and exclusions (material and non-material)

Effective DateJul 1, 2025

Next Review Date

On This Page

Unproven / Not Medically Necessary (Members under 18)

The following uses of TMS in members under 18 are unproven and not medically necessary due to insufficient evidence of efficacy:

Transcranial magnetic stimulation (TMS) for treating all medical (i.e., non-behavioral) conditions

Alzheimer's disease

Dystonia

Chronic neuropathic pain

Epilepsy

Headaches

Parkinson's disease

Stroke

Tinnitus

Traumatic Brain Injury (TBI)

Theta-burst stimulation including accelerated and/or MRI-guided protocols

Navigated transcranial magnetic stimulation (nTMS) for treatment planning or for diagnosing motor neuron diseases or neurological disorders

Unproven and Not Medically Necessary Services (excerpted changes)

As revised 07/01/2025, the following services are considered unproven and not medically necessary:

Transcranial magnetic stimulation (TMS) for treating epilepsy

Transcranial magnetic stimulation (TMS) for treating Parkinson's disease

Transcranial magnetic stimulation (TMS) for treating tinnitus

Navigated transcranial magnetic stimulation (nTMS) for treatment planning

nTMS for diagnosing motor neuron diseases or neurological disorders

Theta-burst stimulation including accelerated and/or MRI-guided protocols

TMS for behavioral disorders not addressed in InterQual criteria (refer to Optum Behavioral Clinical Policies)

For members under 18 years of age: TMS for conditions including but not limited to Alzheimer's disease, chronic neuropathic pain, dystonia, headaches, stroke, traumatic brain injury (TBI) (listed as unproven/not medically necessary due to insufficient evidence)

Quick evidence summary (key entries)

InterQualReferenced as the primary source for adult medical necessity determinations for TMS

NICE guidance (2014/2018)NICE: TMS for migraine only with special arrangements; do not offer NIBS for AD except in RCTs

Cochrane short‑term pain meta‑analysis27 rTMS studies (655 participants): small short‑term effect equating to 7% pain reduction (0.40/0–10), below MCID

Tinnitus meta‑analyses12–29 RCTs pooled; pooled analyses show improved THI/TQ scores at various timepoints but guideline (AAO‑HNS) advises not to recommend TMS for persistent bothersome tinnitus

nTMS surgical outcomes meta‑analysisRaffa et al. meta‑analysis: nTMS motor mapping associated with reduced risk of postoperative permanent motor deficits (OR 0.54) and increased gross total resection

nTMS single‑center series (Sollmann et al.)Case series (60 pts) using preop nTMS + DTI‑FT: 28.3% residual tumor; 8.3% new permanent language deficits; authors call for randomized trials

Theta‑burst (general) statementEvidence lacking for accelerated, MRI‑guided theta‑burst protocols; insufficient evidence to conclude benefit

Documentation Required

Use of InterQual/Optum criteria for medical necessity

When making medical necessity determinations, use InterQual's TMS criteria for primary medical/surgical indications and refer to Optum Behavioral Clinical Policies for behavioral disorders not covered by InterQual. Note that federal, state (Ohio Administrative Code), or contractual requirements supersede this policy when conflicts exist and should be followed.

Prior Authorization

Prior authorization and coverage determination

Providers should obtain prior authorization and follow plan-specific coverage determination processes per UnitedHealthcare and InterQual guidance; coverage determinations for TMS therapies follow InterQual criteria and UnitedHealthcare policies and are subject to applicable state and federal rules.

Obtain prior authorization per plan requirements
Verify applicable state (OAC 5160-1-01) or federal/contractual coverage rules
Reference InterQual CP: Procedures, Transcranial Magnetic Stimulation (TMS) for criteria