Transcranial magnetic stimulation (TMS) is a method of noninvasive stimulation of the brain through a small coil placed over the scalp to produce a magnetic field that will stimulate the cortex of the brain. TMS is used in the treatment of major depressive disorders and obsessive-compulsive disorders (OCD) that are resistant to treatment.

Repetitive transcranial magnetic stimulation (rTMS) of the brain using an FDA-cleared device may be considered medically necessary as a treatment of major depressive disorder when ALL of the following conditions have been met:

• The individual is age 15 or older
• The individual has a confirmed diagnosis of severe major depressive disorder (single or recurrent) documented by standardized rating scales that reliably measure depressive symptoms, such as Hamilton depression scale
• Treatment is indicated by ONE or more of the following
  • The individual has tried and had an inadequate response to two (2) antidepressant agents from two (2) different antidepressant classes (i.e., selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, bupropion, or mirtazapine) and ALL of the following are met
    • The trial length was at least 6 weeks at generally accepted doses or sufficient duration as determined by the treating physician at the generally accepted doses
    • The individual was at least 80% adherent to the agent during the trial
  • The individual is unable to tolerate a therapeutic dose of medications as evidenced by two (2) trials of psychopharmacologic agents with distinct side effects
  • The individual has a history of positive response to rTMS, as documented by standardized rating scales that reliably measure depressive symptoms, in a previous depressive episode (at least three (3) months since the prior episode)
  • The individual is a candidate for electroconvulsive therapy (ECT) and ECT would not be clinically superior to rTMS (e.g., in cases with psychosis, acute suicidal risk, catatonia or life-threatening inanition rTMS should NOT be utilized)

• The individual has failed a trial of a psychotherapy known to be effective in the treatment of major depressive disorder of an adequate frequency and duration, without significant improvement in depressive symptoms, as documented by standardized rating scales that reliably measure depressive symptoms

• The individual has NONE of the following conditions
  • Seizure disorder or any history of seizure with increased risk of future seizure
  • Presence of acute or chronic psychotic symptoms or disorders (such as schizophrenia, schizophreniform or schizoaffective disorder) in the current depressive episode
  • 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 (CNS)
  • Presence of an implanted magnetic-sensitive medical device located 30 centimeters or less from the TMS magnetic coil or other implanted metal items, including but not limited to a cochlear implant, implanted cardioverter defibrillator (ICD), pacemaker, vagus nerve stimulator, or metal aneurysm clips or coils, staples, or stents.
• Prescribed treatment does not exceed five (5) days a week for six (6) weeks (total of 30 sessions), followed by a three (3)-week taper of three (3) TMS treatments in week one (1), two (2) TMS treatments the next week, and one (1) TMS treatment in the last week

NOTE: A facility providing TMS is required to have ALL of the following

• A physician who is adequately trained and experienced in the specific techniques used
• An attendant trained in basic cardiac life support and the management of complications such as seizures, as well as the use of the equipment who is present at all times
• Adequate resuscitation equipment including suction and oxygen
• Awareness of response times of emergency services (either fire/ambulance or “code team”), which should be available within five (5) minutes. These relationships are reviewed on at least a one (1) year basis and include mock drills.

rTMS for major depressive disorder that does not meet the criteria listed above is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Continued treatment with rTMS of the brain as maintenance therapy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Repetitive transcranial magnetic stimulation (rTMS) of the brain using an FDA-cleared device may be considered medically necessary as a treatment of obsessive-compulsive disorder when ALL of the following conditions have been met

• The individual is age 18 or older
• The individual has a confirmed diagnosis of obsessive-compulsive disorder (OCD) documented by standardized rating scales that reliably measure symptoms such as Yale-Brown Obsessive-Compulsive Scale (YBOCS)
• Treatment is indicated by ONE or more of the following
  • The individual is resistant to treatment as evidenced by persistent OCD symptoms after two (2) indicated therapies (two (2) medications or one (1) medication plus psychotherapy) were tried each for a minimum of eight (8) weeks (cognitive behavior therapy (CBT) psychotherapy, while a valuable treatment option, is not required as a pre-requisite to TMS OCD treatment)
  • The individual is unable to tolerate psychopharmacologic agents as evidenced by trials with two (2) psychopharmacologic agents with distinct side effects
  • The individual has a history of positive response to rTMS for OCD (as documented by standardized rating scales that reliably measure symptoms of OCD), and at least three (3) months have elapsed since the prior treatment
  • The individual is currently receiving antipsychotics, opioids, benzodiazepines, glutamatergic agents or other agents which could be considered investigational or relatively risky treatments, and TMS may be considered medically necessary and a safer alternative than additional treatment trials.

• The individual has NONE of the following conditions
  • Seizure disorder or any history of seizure with increased risk of future seizure
  • Presence of acute or chronic psychotic symptoms or disorders (such as schizophrenia, schizophreniform or schizoaffective disorder) in the current OCD episode
  • 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 (CNS)
  • Presence of an implanted magnetic-sensitive medical device located 30 centimeters or less from the TMS magnetic coil or other implanted metal items, including but not limited to a cochlear implant, implanted cardioverter defibrillator (ICD), pacemaker, vagus nerve stimulator, or metal aneurysm clips or coils, staples, or stents. 
• Prescribed treatment does not exceed 29 visits over a six (6) week period

NOTE: A facility providing TMS is required to have ALL of the following

• A physician who is adequately trained and experienced in the specific techniques used
• An attendant trained in basic cardiac life support and the management of complications such as seizures, as well as the use of the equipment who is present at all times
• Adequate resuscitation equipment including suction and oxygen
• Awareness of response times of emergency services (either fire/ambulance or “code team”), which should be available within five (5) minutes. These relationships are reviewed on at least a one (1) year basis and include mock drills.

rTMS for obsessive-compulsive disorder that does not meet the criteria listed above is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Retreatment may be considered for patients who met the guidelines for initial treatment and experienced at least a 30% reduction in the YBOCS score, as long as the improvement persisted for at least one month after the prior treatments ended.

Retreatment with rTMS for OCD not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

TMS of the brain is considered experimental/investigational and therefore non-covered for any other indication, including, but not limited to Alzheimer’s disease because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.