Highmark Commercial Medical Policy - West Virginia |
Medical Policy: | Z-4-006 |
Topic: | Transcranial Magnetic Stimulation (TMS) |
Section: | Miscellaneous |
Effective Date: | October 20, 2014 |
Issue Date: | October 20, 2014 |
Last Reviewed: | August 2014 |
Repetitive transcranial magnetic stimulation (rTMS) of the brain may be considered medically necessary as a treatment of major depressive disorder when ALL of the following conditions have been met:
AND
rTMS should be performed using an FDA-cleared device in appropriately selected patients, by physicians who are adequately trained and experienced in the specific techniques used. A treatment course should not exceed 5 days a week for 6 weeks (total of 30 sessions), followed by a 3-week taper of 3 TMS treatments in week 1, 2 TMS treatments the next week, and 1 TMS treatment in the last week. All of the following should be present for the administration of rTMS and documented in the medical record and available upon request:
rTMS for major depressive disorder that does not meet the criteria listed above is considered experimental/investigational and therefore, not covered. A participating, preferred, or network provider can bill the member for the non-covered service. Continued treatment with rTMS of the brain as maintenance therapy is considered experimental/investigational and therefore, not covered. A participating, preferred, or network provider can bill the member for the non-covered service. Transcranial magnetic stimulation of the brain is considered experimental/investigational and therefore not covered for any other indication. There is insufficient evidence in medical literature to support the effectiveness of this procedure. A participating, preferred, or network provider can bill the member for the denied service. Place of Service: Outpatient TMS is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting. Description
Transcranial magnetic stimulation (TMS) is a method of noninvasive stimulation of the brain through a small coil placed over the scalp. A rapidly alternating current is then passed through the coil wire, producing a magnetic field that passes unimpeded through the scalp and bone, resulting in electrical stimulation of the cortex. TMS was initially used to investigate nerve conduction. For example, TMS over the motor cortex will produce a contralateral muscular-evoked potential. This “motor threshold” (MT), which is the minimum intensity of stimulation required to induce a motor response, is empirically determined for each individual by gradually increasing the intensity of stimulation. TMS has been investigated as a treatment for major depressive disorders that are resistant to treatment. It is also being tested as a treatment for other disorders including, but not limited to, schizophrenia, obsessive-compulsive disorder, and bulimia. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
The policy position applies to all commercial lines of business |
FEP Guidelines |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
Denial Statements |
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