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Coverage criteria policies

Repetitive transcranial magnetic stimulation

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for Repetitive Transcranial Magnetic Stimulation.

Coverage

Repetitive Transcranial Magnetic Stimulation is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Transcranial magnetic stimulation (TMS) is considered medically necessary in adults who have a confirmed diagnosis of major depressive disorder (MDD), single or recurrent episode and meet the following criteria:

  1. Resistance to treatment as evidenced by a lack of a clinically significant response to four (4) trials of psychopharmacologic agents in the current depressive episode;
    1. Two different agent classes, at or above the minimum effective dose and duration and includes trials of at least two (2) evidence-based augmentation therapies; or
  2. Inability to tolerate psychopharmacologic agents as evidenced by four (4) trials of psychopharmacologic agents with distinct side effects; or
  3. History of response to TMS in a previous depressive episode; or
  4. History of response to electroconvulsive therapy (ECT) in a previous or current MDD episode, or inability to tolerate ECT, and TMS is considered a less invasive treatment option; and
  5. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales that reliably measure depressive symptoms; and
  6. The TMS treatment is delivered by a device that is FDA-approved or –cleared for the treatment of MDD in a safe and effective manner. TMS treatment should generally follow the protocol and parameters specified in the manufacturer’s user manual, with modifications only as supported by the published scientific evidence base; and
  7. The order for treatment (or retreatment) is written by a physician (MD or DO) who has examined the patient and reviewed the record. The physician must have experience in administering TMS therapy and the treatment must be given under direct supervision of this physician, i.e., he or she must be in the area and be immediately available

Limitations

The benefits of TMS use must be carefully considered against the risk of potential side effect in patients with any of the following:

  1. Seizure disorder or any history of seizure (except those induced by ECT or isolated febrile seizures in infancy or childhood without subsequent treatment or recurrence). Additional consideration should be given for individuals on medications which may lower the seizure threshold or with conditions rendering the patient more prone to seizures, such as alcoholism;
  2. Presence of vagus nerve stimulators leads in the carotid sheath;
  3. Presence of an implanted medical device located <30 cm from the TMS magnetic coil, including but not limited to pacemakers, implanted defibrillators, or vagus nerve simulators.

Indications that are not covered

TMS is not considered reasonable and necessary for any of the following:

  1. Presence of psychotic symptoms in the current depressive episode;
  2. Acute or chronic psychotic disorder such as schizophrenia, schizophreniform disorder, or schizoaffective disorder;
  3. Neurologic conditions that include epilepsy, cerebrovascular disease, dementia, increased intracranial pressure, having a history of repetitive or severe head trauma, or with primary or secondary tumors in the central nervous system;
  4. Persons with conductive, ferromagnetic or other magnetic-sensitive metals implanted in their head which are non-removable and within 30 cm of the TMS magnetic coil. Examples include cochlear implants, implanted electrodes/stimulators, aneurysm clips or coils stents, and bullet fragments. (Dental amalgam fillings are not affected by the magnetic field and are acceptable for use with TMS.)
  5. Maintenance therapy is not currently supported by evidence from clinical trials and therefore, is considered not reasonable and necessary.
  6. All other conditions not included in the above list of “Indications”.

Definitions

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.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:

CPT Code

Description

90867

Therapeutic repetitive transcranial magnetic stimulation treatment; planning

90868

Therapeutic repetitive transcranial magnetic stimulation treatment; delivery and management, per session

90869

Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management

ICD-10 Code

Description

F32.2

Major depressive disorder, single episode, severe without psychotic features

F33.2

Major depressive disorder, recurrent severe without psychotic features

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

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. The general Medicare web site for their Coverage Issues Manual can be viewed at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
  2. National Government Services Local Coverage Determination (NGS LCD) for Transcranial Magnetic Stimulation (L33398) for services performed on or after 10/1/2015.Link

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Policy activity

  • 07/22/2010 - Date of origin
  • 04/19/2017 - Effective date
Review date
  • 07/2018
Revision date
  • 07/20/2016

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