Retroactively effective to July 1, 2024, Independence Blue Cross (IBX) has updated its policy coding and criteria on Therapeutic Transcranial Magnetic Stimulation (TMS).
Commercial policy updates
The following policy criteria will be revised:
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Clarify that medication trials must be from at least two different agent classes (e.g., selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs], tricyclic antidepressants [TCAs]) and may include FDA-approved augmentation agents.
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Increase the number of trials an individual must demonstrate an intolerance to from two to four agents.
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Remove an individual must be a candidate for ECT.
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Add active substance use disorder must be absent to undergo rTMS.
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Change treatment period from 30 sessions over seven weeks with six tapered treatment sessions to 30 treatment sessions over six weeks followed by a three-week tapering period of three TMS treatments in week one, two TMS treatments the next week, and one TMS treatment in the last week.
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The retreatment criteria will be updated to reflect this updated treatment period.
The following service will be added as medically necessary:
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Accelerated theta burst stimulation (e.g., Stanford Accelerated Intelligent Neuromodulation Therapy [SAINT] protocol) for 10 daily sessions over five consecutive days.
The following services will be added as experimental/investigational:
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TMS treatment beyond 36 sessions
Additionally, CPT® codes 0889T, 0890T, 0891T, and 0892T will be added to this policy as medically necessary.
Medicare Advantage policy updates
The following policy criteria will be revised:
FROM: The individual has demonstrated medication treatment resistance during the current depressive episode as evidenced by lack of a clinically significant response to at least one or more failed trials of psychopharmacologic agents.
TO: The individual has demonstrated a failure of one or more medical trials at adequate dose and duration that are consistent with the FDA label and with a duration that would elicit a favorable response trials of a pharmacological medication.
The following policy criteria will be removed:
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Pregnancy must be absent.
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Concomitant esketamine intranasal, ketamine infusion, or other infusion therapies for major depressive disorder must be absent.
Stanford Neuromodulation Therapy or Stanford Accelerated Intelligent Neuromodulation Therapy (SNT/SAINT) will be added to this policy as medically necessary.
Additionally, CPT codes 0889T, 0890T, 0891T, and 0892T will be added to this policy as medically necessary.
For more information
Please refer to the following policies in Notification status. Note: These policy notifications and their included links will expire and become unusable on December 2, 2024, when the new policy is issued:
To access the most updated version of any active policy, please refer to the Medical and Claim Payment Policy Portal or simply navigate to the Commercial or Medicare Advantage policy bulletins.
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