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Coverage criteria policies

Repetitive transcranial magnetic stimulation – Minnesota Health Care Programs

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 not required for Repetitive Transcranial Magnetic Stimulation.

Coverage

  • Repetitive Transcranial Magnetic Stimulation is not a covered service under Minnesota Health Care Programs.

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 1-800-233-964

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Policy activity

  • 08/22/2016 - Date of origin
  • 04/19/2017 - Effective date
Review date
  • 07/2017

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