BH Transcranial Magnetic Stimulation Form

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Transcranial Magnetic Stimulation (TMS) – Behavioral Health Policy
Updated Revision Effective: June 1, 2024 Policy Number: BH368POL

Approval Date: 12/29/2023

Line(s) of Business:
Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Transcranial magnetic stimulation (TMS) is a noninvasive method of brain stimulation. The technique involves placement of a small coil over the scalp and passing a rapidly alternating current through the coil wire which produces a magnetic field that passes unimpeded through the brain. Depending on stimulation parameters (frequency, intensity, pulse duration, stimulation site), repetitive TMS (rTMS) to specific cortical regions can either increase or decrease the excitability of the affected brain structures. The procedure is usually carried out in an outpatient setting and does not require anesthesia or analgesia.

Policy

Commercial:
Refer to criteria under Policy section in this medical policy.

Medicare:
Health New England follows Local Coverage Determination (LCD) L33398 Transcranial Magnetic Stimulation found at https://www.cms.gov/medicare-coverage-database/search.aspx

For both Commercial and Medicare:  Approval for TMS treatment will be for 1 unit of 90867, 35 units of 90868, and 1 unit of 90869; approval of any additional units must be supported by documentation and will be reviewed on a case-by-case basis.  Services will be approved for 12 weeks

Medicaid – BeHealthy:
Medical necessity review is performed by the Massachusetts Behavioral Health Partnership (MBHP).

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Clinical Guidelines

I. Clinical Criteria for Commercial members

A. Members being referred for TMS must present with Treatment Resistant Depression as evidenced by:

1. Resistance to or inability to tolerate psychopharmacological agents as evidenced by

   a. lack of clinically significant response to four recent adequate trials of at least 6 weeks duration of psychopharmacologic agents in the current depressive episode from at least two different agent classes,

   OR

   b. inability to tolerate psychopharmacologic agents as evidenced by four recent trials of psychopharmacologic agents from at least two different agent classes (at least one of which is in the antidepressant class), with distinct side effects,

   AND

2. Completion of a trial of psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without significant improvement in depressive symptoms during the current depressive episode.

   B. The UM Reviewers will review the prior authorization request for TMS according to the following specific criteria:

3. Member must have a current DSM-5 diagnosis of severe Major Depressive Disorder (MDD), single or recurrent episode, without psychotic features (F32.2 or F33.3), including documentation of baseline depression severity on HAM-D, MADRS, PHQ-9, BDI, or other appropriate tool to assess the severity of depression;

   AND

4. Member must have a recent treatment history that meets all three of the A. criteria above.

   AND

5. Member must have

   a. been offered and declined trial of Electroconvulsive Therapy (ECT) during the current episode, if clinically appropriate;

   OR

   b. have a history of non-response or adverse effects from ECT in the past

   AND

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4. Referrals to a TMS provider must be initiated by one of the member’s ongoing licensed providers, such as a psychiatrist, psychiatric nurse practitioner or psychotherapist. The referring individual should be identified on the TMS Prior Authorization form.

   The TMS Prior Authorization form must be submitted by the member’s ongoing psychiatric provider OR by the potential TMS psychiatrist; provided that this psychiatrist has performed their own full evaluation of the member and determined that they are an appropriate candidate for TMS treatment. In this case, HNE requests that a copy of this evaluation be attached to the prior authorization request. Additionally, in all cases HNE requests that specific information (i.e., dates, doses, responses) pertaining to the member’s most recent history of psychiatric medication trials and psychotherapy be attached to the prior authorization request.

   AND

5. The psychiatrist to perform TMS treatment must have demonstrated to HNE that they have appropriate training in this procedure.

   C. HNE covers repeated use of TMS for an acute relapse of a depressive episode as medically necessary when both of the following criteria are met:

6. All of the criteria for initial therapy are met,

   AND

7. Member had more than a 50% improvement in prior TMS treatment episode(s) as evidenced by a validated rating scale for depressive symptoms.

   D. HNE considers TMS maintenance therapy for depression to be experimental and investigational because the effectiveness and safety has not been established, and therefore this is not a covered service.

   E. The following potential contraindications to TMS treatment have been considered by the provider, and if present, the provider has submitted to HNE an adequate clinical rationale of the safety and appropriateness of proceeding with TMS treatment, despite the contraindication(s):

8. Seizure disorder or any history of seizures (except those induced by ECT or isolated febrile seizures in infancy without subsequent treatment or recurrence)

9. Presence of acute or chronic psychotic symptoms in the current depressive episode

10. Neurological conditions that include epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, or primary or secondary tumors of the CNS

11. Presence of an implanted magnetic-sensitive medical device located less than or equal to 30 cm from the TMS magnetic coil, or other implanted metal items, including but not limited to cochlear implant, implanted cardiac defibrillator (ICD), pacemaker, vagus nerve stimulator, or metal aneurysm clips or coils, staples, or stents. Dental amalgam fillings are not affected by the magnetic field and are acceptable for use with TMS.

12. Patient is currently pregnant or nursing.

13. Patient has a current suicide plan or recent suicide attempt.

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7. Patient has a current or recent history of a Substance Use Disorder, an Eating Disorder, Obsessive- Compulsive Disorder, or Post-traumatic Stress Disorder.

8. Patient has any history of Bipolar Disorder or a Psychotic disorder, including Schizophrenia, Schizoaffective Disorder, and other DSM-5 Psychotic Disorders.

   F. The TMS treatment is delivered by a device that is FDA approved or FDA cleared for the treatment of MDD in a safe and effective manner.

   Coding Guidance

   Code
   Description
   PA 90867 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management Yes 90868 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session Yes 90869 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management Yes

   CPT® Copyright 2023 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

   Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

   References

   Comparative Effectiveness Review of High-Frequency Left Repetitive Transcranial Magnetic Stimulation Versus Other Neurostimulation Approaches to Treatment-Resistant Depression, December 1, 2016.

   High-Frequency Left Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Major Depressive Disorder, November 3, 2016.

   Transcranial Magnetic Stimulation to Enhance Pharmacotherapy for Depression, March 19, 2014.

   All above reports available at:

   https://www.hayesinc.com/

   Policy Implementation

   Approved by the Medical and Pharmacy Policy Committee

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Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 2/17/2010 Initial Policy Date 12/2023 Moved to new template with no changes to criteria.
3/2024 Reviewed with no changes

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.