UnitedHealthcare TMS Coverage Update (Tennessee)

Coverage Summary

This policy defines UnitedHealthcare Community Plan medical policy for the use of transcranial magnetic stimulation (TMS) and related modalities to treat non-behavioral (physical and neurological) health conditions for Tennessee Medicaid and CoverKids members. It applies specifically to Medicaid and CoverKids in Tennessee and lists relevant procedure codes for reference (inclusion of a code does not imply coverage).

The document-level coverage stance is Not Covered / Considered Unproven and Not Medically Necessary for TMS when used for non-behavioral medical indications (see formal list of examples below). The policy number is CS124TN.N and the effective date is April 1, 2026.

Selected Policy Statistics

Examples-not-covered count9+

CPT/HCPCS codes listed count9

FDA product codes count6

Consistency/heterogeneityheterogeneous

Typical study sizemostly small samples

Medical-Necessity Criteria

Medically Necessary Determination / Unproven and Not Medically Necessary

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

ALL of the following

TMS Indications Not Covered (examples include but not limited to)
- Alzheimer disease
- Chronic neuropathic pain
- Dystonia
- Epilepsy

Not Covered / Experimental

The policy states that TMS for all medical (non-behavioral) conditions is considered unproven and not medically necessary due to insufficient evidence. Examples specifically listed include Alzheimer disease, chronic neuropathic pain, dystonia, epilepsy, headaches, Parkinson disease, stroke, tinnitus, and traumatic brain injury (not an exhaustive list).

Additionally, the policy identifies navigated transcranial magnetic stimulation (nTMS) for treatment planning or diagnostic use and theta-burst stimulation (TBS), including accelerated and MRI-guided protocols, as unproven and not medically necessary. The formal list of unproven/not medically necessary items and criteria appear in the policy's Medically Necessary Determination / Unproven and Not Medically Necessary section (criteria group).

The policy applies only to non-behavioral conditions; behavioral disorder indications are addressed separately under the Optum Behavioral Clinical Policy (Transcranial Magnetic Stimulation) referenced by the policy.

Coding

Relevant Procedure Codes (listed for reference; inclusion does not imply coverage)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.

FDA product codes referenced (informational)mixed

GWF	FDA product code referenced for TMS devices
HAW	FDA product code referenced for TMS devices
IKN	FDA product code referenced for TMS devices
OBP	FDA product code referenced for TMS devices
OCI	FDA product code referenced for TMS devices
OKP	FDA product code referenced for TMS devices

Provider Actions

Documentation Required

Behavioral vs Non-Behavioral Referral

Behavioral disorder indications (e.g., psychiatric/behavioral conditions) should be referred to the Optum Behavioral Clinical Policy. This Tennessee-specific policy governs non-behavioral/medical indications for Tennessee Medicaid and CoverKids; it does not apply to behavioral disorder coverage determinations.

This policy governs non-behavioral/medical indications for Tennessee Medicaid/CoverKids.

Documentation Required

Use policy as interpretive guidance

When determining coverage, reference applicable federal, state, or contractual benefit plan requirements first. UnitedHealthcare Medical Policies are informational and may be modified; they do not replace or override member-specific benefit plan documents or legal requirements.

UnitedHealthcare policy is informational and may be modified.

Background and Evidence Summary

Transcranial magnetic stimulation (TMS) is a noninvasive method that uses magnetic field pulses to induce electrical currents in the brain; single-pulse TMS is used for mapping, and repetitive TMS (rTMS) is used to induce longer-lasting changes in brain activity. Navigated TMS (nTMS) uses imaging/navigation to target precise cortical locations and is being studied for diagnostic mapping and surgical planning.

Theta-burst stimulation (TBS) is a form of rTMS delivering short bursts of high-frequency pulses with specific interburst intervals; accelerated and MRI-guided theta-burst protocols are under investigation. The evidence base is limited by mostly small sample sizes, heterogeneity in stimulation techniques and outcome measures, and generally short follow-up periods, limiting conclusions about clinical efficacy and long-term benefit.

Evidence topic	Key point
Alzheimer disease	Multiple RCTs and meta-analyses report mixed and inconclusive cognitive benefits; some studies show short-term improvements vs sham but evidence limited by small samples, heterogeneity, and methodological bias; NICE does not recommend outside trials.
Epilepsy	Cochrane reviews found low to very-low certainty evidence for seizure reduction; some trials show reductions in epileptiform discharges but overall efficacy remains unproven.
Headache (Migraine)	Some RCTs and meta-analyses suggest HF-rTMS may reduce migraine frequency or monthly headache days, but results are heterogeneous and limited; NICE recommends use only with special arrangements or research.
Parkinson disease	Meta-analyses report modest short-term motor and gait improvements (HF-rTMS, M1 target favored), with heterogeneity in protocols and limited long-term data; subgroup findings suggest multisession/bilateral and higher pulse totals may yield larger effects.
Pain (Chronic/Neuropathic)	Systematic reviews report transient short-term pain reductions with HF-rTMS targeting M1 for some neuropathic pain conditions; overall evidence certainty low and clinical effects often below MCID; results variable across conditions.
Stroke	Systematic reviews and RCTs indicate LF-rTMS or HF-rTMS can improve some motor outcomes (upper/lower extremity, balance) in selected trials, but findings are heterogeneous and overall evidence is preliminary.
Tinnitus	Multiple meta-analyses of RCTs found active rTMS superior to sham on THI scores at various follow-up times (up to 6 months), but guideline groups have cautioned and larger confirmatory trials are needed.
Traumatic brain injury (TBI)	Small RCTs show no clear cognitive benefit of rTMS versus sham in chronic diffuse axonal injury; evidence limited by small samples and heterogeneity.
Navigated TMS (nTMS)	Observational studies and systematic reviews suggest nTMS motor mapping may reduce postoperative motor deficits and increase gross total resection rates in tumor surgery, but RCT data are lacking; insufficient evidence for diagnostic/treatment planning conclusions.
Theta-burst stimulation (including accelerated/MRI-guided)	Pilot and small trials show preliminary signals (e.g., memory/connectivity, inconclusive OCD results), but accelerated or MRI-guided TBS lacks sufficient clinical/safety data to conclude benefit; overall evidence insufficient.

Evidence Conclusion

Overall evidence conclusion (accelerated/MRI-guided TBS)Studies demonstrating clinical use and safety are lacking; insufficient evidence to conclude benefit.

Definitions

Glossary:

nTMS: Navigated transcranial magnetic stimulation — TMS technology that uses imaging/navigation to stimulate precise anatomical cortical locations; investigated for diagnostic mapping and treatment planning.

rTMS: Repetitive transcranial magnetic stimulation — repeated pulses of TMS intended to induce longer-lasting changes in brain activity.

TBS: Theta-burst stimulation — a form of rTMS delivering short bursts of high-frequency pulses with specific interburst intervals; includes accelerated and MRI-guided protocols under investigation.

HF-rTMS: High-frequency rTMS — rTMS delivered at higher stimulation frequencies (commonly ≥5–10 Hz) used in many therapeutic protocols.

LF-rTMS: Low-frequency rTMS — rTMS delivered at lower stimulation frequencies (commonly ~1 Hz).

DLPFC: Dorsolateral prefrontal cortex — a common cortical target for TMS protocols.

M1: Primary motor cortex — another common TMS target, particularly for pain and motor recovery studies.

THI: Tinnitus Handicap Inventory — a patient-reported outcome measure used in tinnitus studies.

Revision History

2026-04-01revisedLatest

Title changed from 'Transcranial Magnetic Stimulation (for Tennessee Only)' and supporting information sections (Description of Services, Clinical Evidence, References) were updated.

OpenPayer

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