Point32 Transcranial Magnetic Stimulation (rTMS) Form

Transcranial magnetic stimulation (TMS) uses a specifically designed magnetic coil that is placed in contact with the scalp to generate rapidly alternating magnetic fields and produces electrical stimulation of superficial cortical neurons. The procedure is generally administered daily over a four-to-seven-week period. The FDA approved rTMS in October 2008 for use in the treatment of treatment-refractory Major Depressive Disorder based on the results of a multisite randomized controlled clinical trial using high frequency pulses over the left prefrontal cortex (HFL-TMS).HFL-rTMS requires no anesthesia or sedation

Clinical Guideline Coverage Criteria

The Plan requires the use of the following InterQual Subsets or SmartSheets to obtain prior authorization for transcranial magnetic stimulation (TMS):

1. Transcranial Magnetic Stimulation (TMS)
   • Requested Service: Repetitive Transcranial Magnetic Stimulation
2. Transcranial Magnetic Stimulation (TMS)
   • Requested Service: Repetitive Transcranial Magnetic Stimulation taper

Limitations

The Plan considers transcranial magnetic stimulation (TMS) as not medically necessary for ANY of the following:

1. For forms other than HFL-TMS, as their use is considered experimental
2. TMS should not be used for Members who have conductive, ferromagnetic or other magnetic-sensitive metals implanted in their head and located less than 30 cm from the TMS magnetic coil, including but not limited to cochlear implants, implanted electrodes or stimulators, aneurysm clips or coils, or bullet fragments
3. In a setting other than a medical office or facility.
4. The use of TMS as a maintenance therapy to prevent relapse is not supported by controlled clinical trials and is therefore not considered medically necessary

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