Retroactively effective from July 1, 2019, through June 30,
2020, Magellan Healthcare, Inc. (Magellan) is utilizing updated care
guidelines to determine the medical necessity for transcranial magnetic
stimulation (TMS).
Independence has contracted with Magellan to perform utilization
management activities for behavioral/mental health for members enrolled in an
Independence health plan that offers behavioral health services offered through
Magellan.*
*Self-funded groups have the option to select a
behavioral health vendor other than Magellan.
Summary of the changes
Below is a summary of the updates to the medical necessity criteria for
transcranial magnetic stimulation treatment in the 2019 – 2020
Magellan Care Guidelines:
- Clinical evaluation clarification. Clinical evaluation
determines the patient to have a diagnosis of a severe single or recurrent
episode of major depressive disorder confirmed by Diagnostic and
Statistical Manual of Mental Disorder (DSM-5) criteria.
- Medication treatment resistance. A definition of
“good response” was expanded to read: “The patient has a
history of good response to TMS during an earlier episode of the
treatment-resistant major depressive disorder as evidenced by a greater than 50
percent improvement in a standard rating scale for depressive symptoms (e.g.,
PHQ-9, BDI, MADRS, GDS, QIDS, HAM-D, IDS-SR).”
- Transcranial magnetic stimulation retreatment. The TMS
retreatment guideline was expanded to allow adequate time between treatments
for clinical assessment and for assessment via one of the depressive symptoms
rating scales to clearly document that the patient responded and then relapsed,
typically 90 days after their most recent TMS session.
- Intensity and quality of service. The requirement that the
physician be credentialed by Magellan to perform TMS was removed:
“Requesting provider may not be credentialed for accounts that
don’t utilize Magellan’s provider network.”
To review the updates in more detail, please access the 2019 –
2020 Magellan Care Guidelines. Providers may also access a summary of revisions to the guidelines.
Updated policy
Medical Policy #07.03.22d: Transcranial Magnetic Stimulation (TMS) was
updated and posted as a Notification on December 17, 2019, and it will be
effective March 16, 2020.
However, the Magellan Care Guidelines are
retroactively effective from July 1,
2019.
To view the Notification for this policy, please visit our Medical Policy
Portal.
Learn more
For more information on other available tools and resources, please visit
the Magellan
website or go to the NaviNet® web portal (NaviNet Open)
and select Health and Wellness under Administrative Tools
& Resources.
Magellan Healthcare, Inc., an independent company,
manages mental health and substance abuse benefits for most Independence
members.
NaviNet® is a registered trademark of
NantHealth, an independent company.