Transcranial Magnetic Stimulation for Treating Physical Health Conditions
This policy governs UnitedHealthcare Commercial and Individual Exchange coverage determinations for transcranial magnetic stimulation (TMS) when used to treat medical (non-behavioral) conditions. It applies to providers and members under UnitedHealthcare Commercial and Individual Exchange benefit plans.
Policy Summary
PayerUnitedHealthcare
PolicyTranscranial Magnetic Stimulation for Treating Physical Health Conditions
Policy CodePolicy 2026T0536W
Change TypeTitle and content revisionsarchived prior version
Effective DateFeb 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization per the member's UnitedHealthcare Commercial or Individual Exchange plan and document diagnosis, prior therapies, and objective outcome measures to support medical necessity.
Title changed from 'Transcranial Magnetic Stimulation Supporting Information' to the current title and descriptions of services, clinical evidence, and references were updated.
Title changed from 'Transcranial Magnetic Stimulation Supporting Information' to 'Transcranial Magnetic Stimulation for Treating Physical Health Conditions' and Description of Services, Clinical Evidence, and References sections updated.
listedUnproven indications
6+ codesProcedure codes
insufficientEvidence concerns
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n≥8
nTMS studies
Commercial & ExchangeApplicable plans
Coverage Criteria and Evidence Conclusions
Not medically necessary / Unproven indications
The following uses are considered unproven and not medically necessary due to insufficient evidence of efficacy:
Unproven medical indications: Transcranial magnetic stimulation for treating all medical (i.e., non-behavioral) conditions including but not limited to Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches, Parkinson disease, stroke, tinnitus, and traumatic brain injury; navigated transcranial magnetic stimulation for treatment planning or for diagnosing motor neuron diseases or neurological disorders; theta-burst stimulation (including accelerated and/or MRI-guided protocols)
Listed as not medically necessary due to insufficient evidence of efficacy.
Condition-level evidence summaries
Evidence summaries and conclusions reported in the document for specific conditions
Epilepsy evidence: Cochrane and systematic reviews identified small randomized trials (7–8 trials, ~230–241 individuals) with heterogeneous methods; a minority of trials reported large reductions in seizures but overall the certainty of evidence for seizure reduction is low to very low; rTMS may reduce epileptiform discharges but clinical seizure benefit is unproven; adverse events were uncommon but increased seizure frequency occurred in a small number of individuals.
Migraine/headache evidence: Multiple meta-analyses and RCTs (including network meta-analysis of 19 RCTs, n=1,493) report some reductions in monthly migraine days or attack frequency with HF‑rTMS at specific targets (e.g., C3, left DLPFC, M1), but heterogeneity in stimulation parameters, small samples, short follow-up, and inconsistent outcomes make efficacy preliminary; NICE recommends use only with special arrangements.
preliminary and inconclusive; governance/research arrangements may be required
Parkinson disease evidence: Multiple meta-analyses and RCTs (23 studies, 646 individuals) show rTMS can produce short-term and sometimes longer motor function improvements (small to modest effect sizes), with HF‑rTMS targeting M1 or bilateral M1 and multi‑session protocols appearing more effective in some analyses; optimal parameters are not established.
heterogeneous studies; parameter uncertainty
Neuropathic and chronic pain evidence: Systematic reviews and RCTs report mixed findings: some trials and meta-analyses show modest short-term analgesic effects for HF‑rTMS over M1 or left DLPFC in neuropathic and chronic pain, while other pooled analyses find small or nonclinically significant effects; study sizes are small and results heterogeneous.
short-term effects more commonly reported; long-term benefit unclear
Evidence-summary coverage nodes
Coverage stance varies by indication and evidence certainty; summarized evidence nodes below reflect where studies report benefit or inconclusive/insufficient evidence.
Neuropathic pain (M1 stimulation): Multiple randomized trials and systematic reviews indicate HF‑rTMS targeting primary motor cortex (M1) can produce statistically significant but often transient reductions in chronic neuropathic pain; certainty of evidence ranges from very low to low; multiple-session protocols may sustain longer effects.evidence: multiple RCTs with pooled pain reduction estimates
See meta-analyses for magnitude and certainty; effects often transient
DLPFC stimulation for chronic or provoked pain: Systematic review/meta-analysis found significant short-term analgesia with left DLPFC stimulation in neuropathic/provoked pain and midterm/long-term reductions in some pooled analyses, but results vary by condition and publication bias was noted.SMD reported in meta-analysis
Heterogeneity and small studies limit conclusions
Evidence-based coverage considerations for nTMS and TBS
Evidence summary and conditional utility statements for navigated TMS and related procedures
nTMS mapping for brain tumor surgery: Observational studies and systematic reviews/meta-analyses suggest preoperative navigated TMS (nTMS) motor mapping is associated with reduced postoperative permanent motor deficits and increased gross total resection compared with surgery without nTMS; however, evidence is primarily observational and high‑quality randomized trials are lacking.evidence level: observational/meta-analysis; need for RCTs
Promising observational data but RCTs required to establish clinical utility
Limitations of nTMS evidence: Data are limited by small studies, heterogeneous populations, and variable sensitivity/specificity versus direct cortical stimulation (DCS); reported nTMS–DCS motor mapping distances vary (2–16 mm) and sensitivity/specificity ranges are wide.variable (sensitivity 10–100%, specificity 13.3–98%)
Standardized protocols and larger studies needed
Navigated transcranial magnetic stimulation (nTMS) used for treatment planning or diagnostic mapping of motor neuron disease or other neurologic disorders is considered not medically necessary due to insufficient evidence of efficacy. The policy lists nTMS among interventions for which the evidence base is limited by small studies, heterogeneous populations, and weak study designs, and therefore does not support routine coverage for diagnostic or treatment-planning purposes.
Professional guidance recognizes limited evidence for rTMS in chronic headache disorders. The European Headache Federation states that application of noninvasive rTMS for chronic headaches is "not yet evidence based" given the paucity of controlled data, and the NICE guideline (2014) concludes that the quantity and quality of evidence for TMS in migraine prevention and treatment are limited and advises use only with special arrangements for governance, consent, and audit or research. Meta-analyses report preliminary reductions in migraine frequency in small trials but note heterogeneity in stimulation parameters and the need for larger, standardized RCTs.
Routine use of noninvasive brain stimulation (NIBS) modalities, including rTMS and tDCS, for neuropathic pain after spinal cord injury and for several chronic pain conditions is not supported by the current evidence. A pooled analysis of NIBS studies in post-SCI neuropathic pain found no significant benefit versus sham, and Cochrane and other systematic reviews of rTMS in chronic pain report only small, short-term effect sizes with very-low to low certainty and substantial heterogeneity; these data do not justify routine clinical use.
The American Academy of Otolaryngology–Head and Neck Surgery clinical practice guideline (AAO‑HNS) advises that clinicians should not recommend transcranial magnetic stimulation for patients with persistent, bothersome tinnitus.
Coverage determinations based on this Medical Policy must be interpreted in the context of the member specific benefit plan. When the terms of this Medical Policy conflict with a member specific benefit plan document, the member specific benefit plan governs. Prior to applying this policy, verify plan-level coverage, mandates, and any required authorization processes.
Transcranial magnetic stimulation for treating all listed medical (non‑behavioral) conditions in this policy — including but not limited to Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches, Parkinson disease, stroke, tinnitus, and traumatic brain injury — is considered not medically necessary due to insufficient evidence of efficacy.
Routine use of rTMS for seizure reduction in drug‑resistant epilepsy, general prevention of migraine, and neuropathic pain after spinal cord injury is not supported by high‑certainty evidence. Cochrane and systematic reviews identify small, heterogeneous RCTs with low to very‑low certainty for seizure outcomes; meta‑analyses for migraine report preliminary but inconclusive reductions in attack frequency; and pooled NIBS analyses in post‑SCI neuropathic pain show no significant benefit versus sham.
rTMS applied to the dorsolateral prefrontal cortex (DLPFC) or single‑dose high‑frequency rTMS (HF‑rTMS) typically produces small effect sizes in chronic pain trials that do not meet commonly accepted minimal clinically important difference thresholds. For example, pooled short‑term effects equated to approximately a 7% reduction in pain or a 0.4‑point change on a 0–10 scale, below the 15% or 1.5‑point thresholds described in reviews for clinical relevance.
Accelerated, repetitive, MRI‑guided theta‑burst stimulation protocols currently lack sufficient clinical and safety evidence to support routine clinical use. Small RCTs and pilot studies have produced preliminary signals but are inconclusive because of limited sample sizes, heterogeneous designs, and insufficient safety and long‑term outcome data.
Procedure and Product Codes
Applicable procedure CPT/HCPCS 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.
FDA product codes (informational)mixed
GWF, HAW, IKN, OBP, OCI, OKP
FDA product codes referenced for TMS devices
Distance between nTMS and DCS motor mapping points
Reported range2–16 mm
ContextDistance measured between nTMS motor mapping points and intraoperative direct cortical stimulation (DCS) motor points in comparative studies and meta-analyses.
Evidence baseDerived from observational studies and meta-analyses assessing concordance of nTMS vs DCS for motor mapping.
Prior Authorization, Documentation, and Billing Guidance
Prior Authorization
Prior Authorization Required
Prior authorization requirements apply per the member's UnitedHealthcare plan. Verify the member-specific benefit plan and any applicable federal or state mandates before submitting requests; inclusion of procedure codes in this policy is informational and does not guarantee coverage or payment.
Prior authorization may be required by the member's plan — check eligibility and precert rules.
Listing of a code in this policy does not imply the service is covered; use the member specific benefit plan to determine benefits.
Documentation Required
Clinical Justification and Documentation
Requests for TMS, nTMS, or theta-burst stimulation for indications with limited or low-certainty evidence should include clinical justification and documentation of prior therapies and outcomes. Provide detailed trial design and stimulation parameters when a trial of therapy is performed.
Background and Context
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that uses time‑varying magnetic fields to induce electrical currents in the brain. Single‑pulse TMS is used for functional cortical mapping, while repetitive TMS (rTMS) delivers trains of pulses intended to produce lasting changes in cortical excitability. Variants include navigated TMS (nTMS), deep TMS, and patterned protocols such as theta‑burst stimulation (TBS), including accelerated and MRI‑guided approaches; clinical studies have investigated these modalities across multiple medical conditions but evidence quality and consistency vary widely.
Definitions and Key Terms
Theta-burst stimulation — definition and characteristics
DefinitionA patterned form of repetitive transcranial magnetic stimulation (rTMS) delivering short bursts of pulses at a higher within-burst frequency but lower overall frequency.
Common protocols/variantsContinuous TBS (cTBS) and intermittent TBS (iTBS); protocols can be delivered in accelerated schedules or combined with MRI-guidance for connectivity-targeting.
Key characteristicsShort bursts of 3–5 pulses per burst, designed to produce longer-lasting changes in cortical excitability with shorter session durations than conventional rTMS.
Evidence noteAccelerated and MRI-guided TBS protocols currently lack sufficient high-quality evidence of clinical use and safety; further RCTs needed.
Top-level description of TMS modality variants referenced in the policy
Modalities described: rTMS, single‑pulse TMS, navigated TMS (nTMS), deep TMS, theta‑burst stimulation (including accelerated and MRI‑guided protocols), and fMRI‑guided connectivity‑guided intermittent TBS are described and discussed in the evidence base.
Behavioral/psychiatric TMS coverage is governed by a separate behavioral policy.
TMS
General modality description and evidence context for therapeutic TMS
HF‑rTMS therapeutic use: High‑frequency repetitive TMS (HF‑rTMS) has been studied for conditions such as migraine and pain with variable results; specific targets (e.g., left DLPFC, C3, M1) and parameters influence outcomes and evidence is heterogeneous.varies by study
Efficacy preliminary for some targets; trials differ in methods
Policy Summary
PayerUnitedHealthcare
PolicyTranscranial Magnetic Stimulation for Treating Physical Health Conditions
Policy CodePolicy 2026T0536W
Change TypeTitle and content revisionsarchived prior version
Effective DateFeb 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization per the member's UnitedHealthcare Commercial or Individual Exchange plan and document diagnosis, prior therapies, and objective outcome measures to support medical necessity.
Meta-analyses of noninvasive brain stimulation modalities (rTMS, tDCS, CES) found no significant pooled benefit for neuropathic pain after spinal cord injury; routine use is not supported.
no pooled benefit vs sham
insufficient evidence for routine use
Stroke motor recovery: Systematic reviews and network meta-analyses report that LF‑rTMS and HF‑rTMS may improve motor outcomes for some limbs/measures (e.g., Fugl‑Meyer, lower extremity function) depending on modality and target, but heterogeneity of protocols limits firm recommendations.varied by RCT and meta-analysis
benefit measured in specific analyses but overall conclusions limited by heterogeneity
Poststroke neurogenic bladder: A single randomized trial (n=100) reported significant improvement in bladder function and quality of life with LF‑rTMS versus sham; findings are promising but require replication.single RCT positive
replication needed
Tinnitus: Multiple meta-analyses (including 12 RCTs, total n≈717 and larger reviews up to 29 RCTs) report improvements in Tinnitus Handicap Inventory scores with rTMS at short- and medium-term follow-up; guideline recommendations conflict (AAO‑HNS recommends against TMS for persistent bothersome tinnitus based on guideline review).THI score improvements reported
evidence shows score improvements but guideline conflict exists
Traumatic brain injury (cognitive outcomes): Small randomized trials show inconclusive effects of rTMS on cognitive outcomes after traumatic brain injury; evidence insufficient to support routine use.small negative or inconclusive RCTs
Accelerated or MRI‑guided theta‑burst stimulation lacks sufficient clinical and safety evidence to conclude benefit; small RCTs and pilot studies show preliminary signals but are inconclusive due to sample size and design limitations.
insufficient high-quality RCT data
Not established for routine coverage for physical health indications
Document prior conservative treatments (medications, physical therapy, behavioral therapies) and duration of trials.
Include stimulation parameters (site, frequency, intensity, number of sessions), motor threshold determination, and patient-level outcomes (pain scores, migraine days, seizure frequency, urodynamics, validated PROs).
Denial Risk
High Denial Risk for nTMS and Novel TBS Protocols
Requests for navigated TMS (nTMS) for treatment planning or diagnostic evaluation, and for accelerated or MRI‑guided theta‑burst protocols, are at high risk for denial unless strong supporting evidence and documented institutional protocols/registries are provided.
nTMS: provide indication, mapping method, comparison to intraoperative DCS (if available), and how results will change surgical management.
Accelerated/MRI‑guided TBS: include protocol details, prior evidence, and documented participation in a registry or research protocol if applicable.
Note
Evidence Limitations — Expectation of Prior Therapy and Outcomes
When TMS is considered for headache/migraine, epilepsy, chronic pain, post‑stroke bladder dysfunction, or other nonbehavioral neurologic conditions, note that evidence quality is variable (very low to low) and clinical benefit often transient or below MCID. Use of TMS for these indications should meet local prior authorization requirements and be accompanied by outcome measurement.
For migraine, consider NICE recommendation: use only with special arrangements for governance, consent, audit, or research.
For chronic neuropathic pain and post‑SCI pain, document prior therapies and objective pain outcome measures; evidence does not support routine use.
For poststroke neurogenic bladder, limited single‑center data are promising but require replication — document urodynamic and patient‑reported outcomes.
Note
FDA Approval Informational Only
FDA device approvals are informational only and are not, by themselves, a basis for coverage. Provide clinical rationale and evidence demonstrating meaningful improvement in health outcomes when seeking coverage.
Refer to FDA PMN/PMA pages for device specifics when needed.
Document how device use aligns with peer‑reviewed evidence and member plan benefits.
Documentation Required
Special Arrangements / Research Documentation
For TMS requests that will be provided under special governance or research arrangements (for example per NICE guidance for migraine), include documentation of the governance structure, informed consent, audit plan, or registry participation.
Submit protocol, consent forms, and audit or registry plan when required.
If participation in research or registry is asserted, provide enrollment documentation.
Billing Rule
Coding and Benefit Determination
Coding inclusion in this policy is for reference only. Use the member's benefit plan to determine coverage and potential billing. Prior authorization systems may reference procedure codes but do not guarantee payment.
Reference CPT codes 0858T, 0889T–0892T, 90867–90869 when preparing authorization requests, but confirm plan-level coverage.
Provide clinical notes and operative/treatment reports to support billed services.
TMS performed with integration of neuroimaging-based neuronavigation to target precise anatomical cortical locations (often using individual structural MRI), enabling stimulation at defined cortical coordinates.
Primary useInvestigated for preoperative functional mapping (motor and language) and for improving precision of therapeutic stimulation targets.
Evidence limitationsAvailable studies are mainly observational and heterogeneous; larger RCTs are needed to establish diagnostic and treatment-planning utility.
HF-rTMS — high-frequency rTMS definition and common targets
DefinitionHigh-frequency repetitive transcranial magnetic stimulation (HF-rTMS) refers to rTMS protocols using frequencies typically above 1 Hz (commonly 5–20 Hz in trials).
Common cortical targetsPrimary motor cortex (M1) and dorsolateral prefrontal cortex (DLPFC) are frequently targeted in trials for pain, migraine, and Parkinson disease motor symptoms.
Typical effects reportedStudies report short-term analgesic or motor benefits with HF-rTMS; evidence is heterogeneous and effect sizes are often small to modest.
M1 — primary motor cortex definition and relevance
DefinitionPrimary motor cortex (M1) is the region of cerebral cortex responsible for voluntary motor control and is a common stimulation target in TMS studies.
Clinical relevanceM1 stimulation is commonly used in trials for neuropathic and chronic pain, Parkinson disease motor symptom improvement, and for motor mapping in preoperative evaluation.
Mapping utilityActivation of M1 with single-pulse TMS elicits contralateral motor-evoked potentials (MEPs), aiding functional localization and surgical planning.
High-frequency rTMS (HF-rTMS) — protocol frequency examples and targets
Protocol frequency examplesFrequencies reported in reviews and trials include commonly used HF ranges such as 5–20 Hz (examples across studies).
Typical targetsM1 (primary motor cortex) and DLPFC (dorsolateral prefrontal cortex) are common cortical targets for HF-rTMS in pain, migraine, and motor disorders.
Clinical findingsHF-rTMS has shown short-term improvements in pain intensity and motor function in some studies, but heterogeneity and limited sample sizes limit definitive conclusions.
Low-frequency rTMS (LF-rTMS) — definition and common stroke rehab application
DefinitionLow-frequency rTMS (LF-rTMS) typically refers to stimulation around ~1 Hz.
Common applicationOften applied to the unaffected hemisphere in stroke rehabilitation studies to modulate interhemispheric balance and improve motor recovery.
Evidence summaryNetwork meta-analyses report LF-rTMS can improve certain motor function measures (e.g., Fugl-Meyer) after stroke, though results vary by outcome and study quality.
nTMS — definition and primary use for preoperative mapping
DefinitionnTMS (navigated transcranial magnetic stimulation) combines TMS with neuronavigation (often MRI-based) to perform preoperative cortical mapping.
Primary usePrimarily used for preoperative motor and language mapping to assist brain tumor surgical planning and tailor resection strategy.
Evidence limitationsCurrent evidence is mainly observational; meta-analyses suggest associations with reduced postoperative motor deficits and higher GTR rates, but high-level RCT evidence is lacking.
Theta-burst stimulation (TBS) — patterned TMS form and variants
DefinitionTheta-burst stimulation (TBS) is a patterned form of TMS delivered in bursts (e.g., 3–5 pulses per burst) and can be continuous (cTBS) or intermittent (iTBS).
VariantsIncludes cTBS (inhibitory-style) and iTBS (excitatory-style); protocols may be delivered in accelerated schedules or coupled with MRI-guidance for connectivity-targeting.
Evidence noteAccelerated or MRI-guided TBS protocols lack sufficient clinical and safety evidence; existing RCTs and pilot studies are small and inconclusive.
rTMS — repetitive transcranial magnetic stimulation referenced in meta-analyses
DefinitionRepetitive transcranial magnetic stimulation (rTMS) is repeated delivery of TMS pulses intended to induce lasting changes in cortical activity beyond the stimulation period.
Clinical contextsrTMS is studied across multiple physical health indications (e.g., pain, migraine, Parkinson disease, stroke, tinnitus) using varied frequencies, targets, and session schedules.
Evidence characteristicsMeta-analyses and systematic reviews cite heterogeneous protocols and small sample sizes; evidence quality ranges from very low to low for many medical indications.
rTMS and other NIBS
Repetitive TMS and other noninvasive brain stimulation (NIBS) modalities evaluated across indications
rTMS modalities and targets: Multiple rTMS protocols (HF, LF, deep rTMS, theta‑burst) targeting M1, DLPFC, insula, ACC, and supplementary motor area have been studied for physical health conditions with variable evidence by indication.varies by protocol and target
See condition‑level evidence summaries for indication‑specific findings.
TMS / Theta-burst stimulation (TBS)
Theta‑burst stimulation (TBS) modality overview and current evidence limitations
TBS modalities: Theta‑burst stimulation (continuous and intermittent) is a patterned form of rTMS; accelerated and MRI‑guided TBS protocols are being investigated but current clinical evidence and safety data are insufficient to support routine use for physical health conditions.insufficient RCT evidence
Further large, well‑designed trials required
TMS
General TMS evidence references cited in policy literature
rTMS evidence citations: Meta‑analyses and systematic reviews cited for rTMS in mild cognitive impairment, chronic migraine, and other conditions support the referenced evidence summaries; primary studies and reviews are listed in the policy references.