A Premera Blue Cross policy that became effective Jan. 1 outlines when transcranial magnetic stimulation is considered medically necessary for select psychiatric conditions, according to an update issued Dec. 9. The document includes updated parameters for treatment types, session limits and clinical criteria.
Here are five things to know:
- TMS may be covered for unipolar depression, bipolar depression and obsessive-compulsive disorder when severity and medication failure criteria are met.
- Deep TMS and standard repetitive TMS — excluding the SNT/SAINT protocol — are eligible for coverage. Theta burst stimulation is covered only for unipolar depression; its use for bipolar depression and obsessive-compulsive disorder is considered investigational. Other protocols, such as functional MRI-guided or single pulse TMS, are considered investigational.
- Standard and theta burst treatments may include up to 36 sessions; deep TMS may include up to 44 sessions, including tapering phases. Accelerated treatment is allowed up to five sessions per day for standard or deep TMS, and 10 per day for theta burst.
- Patients must be at least 15 years old for unipolar depression and 18 for bipolar or OCD. Required medication failures range from two to three drugs or augmenting agents, depending on the condition.
- Maintenance TMS is covered when previous intensive treatment improved symptoms to moderate, mild or remission. Initial authorization may extend up to 26 weeks, depending on session frequency.
