Medical Policy

TRANSCRANIAL MAGNETIC STIMULATION AS A TREATMENT OF MENTAL ILLNESS AND OTHER BRAIN DISORDERS (REQUIRES PREAUTHORIZATION)

IV.67

IV.67 TRANSCRANIAL MAGNETIC STIMULATION AS A TREATMENT OF MENTAL ILLNESS AND OTHER BRAIN DISORDERS (REQUIRES PREAUTHORIZATION)

Policy

INTERQUAL CRITERIA

Dates

Original Effective
03-27-2002
Last Review
08-07-2024
Next Review
08-11-2025

Description

Transcranial magnetic stimulation (TMS) is a procedure in which magnetic pulses are repeatedly delivered through the scalp to targeted areas of the brain to stimulate groups of neurons and, thereby, relieve certain symptoms or disorders. Several types of repetitive TMS (rTMS) have been demonstrated to be effective for major depressive episodes in patients 18 years or older with major depressive disorder who fail to improve on antidepressant medications.

Deep TMS (dTMS) refers to repetitive TMS (rTMS) delivered by a larger coil with complex windings whose geometry is designed to result in deeper penetration of magnetic pulses. Theta burst stimulation (TBS) is a type of TMS with pulses delivered in very rapid "bundles" or "bursts" which can be delivered in a continuous fashion (continuous theta burst stimulation or cTBS) or as strings of bursts separated by rest intervals (intermittent TBS or iTBS).

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Procedure

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Diagnosis

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Codes

Full Description

Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management

Full Description

Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session

Full Description

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

References

2010 Janicak PG, et al. “Durability of clinical benefit with transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant major depression: assessment of relapse during a 6-month, multisite, open-label study.” Brain Stimulation 2010;3(4):187-199.
2011 Rosenberg O, et al. “Effectiveness of a second deep TMS in depression: a brief report. Prog Neuropsychopharmacol Biol Psychiatry 2011;35(4):1041-1044.
2017 Kelly MS, et al. “Initial Response to Transcranial Magnetic Stimulation Treatment for Depression Predicts Subsequent Response.” J Neuropsychiatry Clin Neurosci. 2017;29(2):179-182.
2016 Philip NS, et al. “Can Medication Free, Treatment-Resistant, Depressed Patients Who Initially Respond to TMS Be Maintained Off Medications? A Prospective, 12-Month Multisite Randomized Pilot Study.” Brain Stimul. 2016;9(2):251-257.
2005 O’Reardon JP, et al. “Long-term maintenance therapy for major depressive disorder with rTMS.” J Clin Psychiatry 2005;66:1524-28.
2012 Connolly KR, et al. “Effectiveness of transcranial magnetic stimulation in clinical practice post-FDA approval in the United States: Results observed with the first 100 consecutive cases of depression at an academic medical center.” J. Clin Psychiatry 2012;73:e567-e573.
2013 Fitzgerald PB, et al., “An open label trial of clustered maintenance rTMS for patients with refractory depression.” Brain Stimulation 2013;6:292-297; Ric-adjusted analysis. Rhieri R, et al. “Maintenance transcranial magnetic stimulation reduces relapse: a propensity-adjusted analysis. J Affect Disord. 2013;151:129-135.
2014 Harel EV, et al. “H-coil repetitive transcranial magnetic stimulation for treatment resistant major depressive disorder: an 18-week continuation safety and feasibility study.” World J Biol Psychiatry. 2014;15:298-306.
2015 Levkovitz Y, et al. “Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial.” World Psychiatry. 2015; 14: 64-73.
2018 Carmi, L., Alyagon, U., Barnea-Ygael, N., et al. Clinical and electrophysiological outcomes of deep TMS over the medial prefrontal and anterior cingulate cortices in OC patients. Brain Stimulation. January-February 2018:11(1); 158-165.
2021 Alyagon, U., Barnea-Ygael, N., Zangen, C.A. Modification of cognitive performeance in teh stroop task following deep rTMS treatment course in OCD patients. Brain Stimulation. 2021:14;48-50.
2020 Roth, Y., Barnea-Ygael, N., Carmi, L., et al. Deep transcranial magnetic stimulation for obsessive-compulsive disorder is efficacious even in patients who failed multiple medications and CBT. Psychiatry Research. August 2020: 290.
2021 Roth, Y., Tendler, A., Arikan, M.K., et al. Real-world efficacy of deep tMS for obsessive-compulsive disorder: Post marketing data collected from twenty-two clinical sites. Journal of Psychiatric Research. May 2021:137: 667-672.
2021 Tendler, A., Roth, Y., Harmelech, T. Deep repetitive TMS with the H7 coil is sufficient to treat comorbid MDD and OCD. May 2021:14(3) 658-661.DOI: https://doi.org/10.1016/j.brs.2021.04.006

Revisions

06-15-2025 Using InterQual Criteria.
08-31-2021 Reviewed on 08/11/2021 with no changes being made to the policy. Adding references
02-23-2021 Updated criteria for recurrence
06-19-2019 Added clarification to policy statement to include: all other indications, including OCD are investigational.
03-18-2013 added any review over 30 tx will require a medical necessity review