Transcranial Magnetic Stimulation (TMS) is a noninvasive method of delivering electrical stimulation to the brain. Brief pulses of magnetic energy are applied to the scalp via an electromagnetic coil to generate low levels of electrical current in underlying brain tissue. The goal of TMS is to stimulate areas of the brain involved in mood regulation in order to lessen the duration or severity of depressive episodes. The procedure is carried out in an outpatient setting and does not require anesthesia.
When used as an antidepressant therapy, TMS produces a clinical benefit without the systemic side effects attendant with standard oral medication. TMS does not have adverse effects on cognition. Unlike electroconvulsive therapy (ECT), TMS does not induce amnesia or seizures.
Coverage criteria:
1. Patient is 18 years of age or older.
2. Patient meets the definition of unipolar major depression as defined by the DSM-5 criteria, with persistent moderate/severe symptoms.
3. Patient demonstrates a history of resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically significant response to 1 medication from at least 2 different classes. Or, the patient is unable to tolerate a therapeutic dose of medications.
4. The current treatment episode must demonstrate a lack of response to an adequate course of mono- or poly- drug therapy. APA practice guidelines for Major Depressive Disorder state adequate treatment with an antidepressant medication for at least 4 to 8 weeks is necessary before concluding that a patient is not responsive or only partially responsive to a particular medication.
5. The TMS treatment itself must be administrated by a TMS trained provider under the supervision of a TMS trained psychiatrist who is on-site (in the building).
6. Patient has moderate to severe depression as defined by use of one of the following validated, evidence-based depression monitoring tools: HAM-D, MADRS or QIDS, IDS-SR, or PHQ-9.
7. If patient is a candidate for electro convulsive therapy, rTMS may be authorized as a less invasive treatment option.
If the above coverage criteria are met, ConnectCare will cover an initial 6 weeks of therapy, up to 30 visits, and 6 taper treatments.
Repeat acute treatment for relapse of depressive symptoms is considered medically necessary if the patient responded to prior treatment, specifically >50% improvement in score by use of validated, evidence-based depression monitoring tool, such as HAM-D, MADRS or QIDS, IDS-SR, or PHQ-9. If the patient meets these criteria, ConnectCare will authorize an additional 30 visits for acute phase treatment followed by additional 6 visits for tapering therapy.
Limitations and Exclusions:
- Most randomized trials on TMS excluded patients with psychosis. A patient with a history of psychosis with stable or no active psychotic symptoms could be a candidate for TMS.
2. Treatment for patients non-compliant with prior therapies is not covered.
3. Treatment for pregnant patients is approved.
4. Treatment is not appropriate if the patient or legal guardian is unable to understand the risks and benefits of rTMS and provide informed consent.
5. Treatment must be provided using a device approved by the FDA for the purpose of supplying Transcranial Magnetic Stimulation, such as Neurostar.
6. Failure to monitor and document patient response will result in denial of further coverage.
Contraindications - Repetitive TMS is contraindicated in patients with:
1. Increased risk for seizures
2. Implanted metallic hardware (e.g. aneurysm clips or bullet fragments
3. Cochlear implants
4. Implanted electrical devices (e.g. pacemakers, intracardiac lines, and medication pumps)
5. Unstable general medical disorders
