0889T — Prsnlz trgt dvl arhfcmrigtbs
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- No explicit documentation requirements (medical records, test results, or specific clinical documentation) are specified in this Medical Policy. The policy instructs to reference the member specific benefit plan document and any applicable federal or state mandates when deciding coverage.
- Documented PHQ-9 score ≥ 15 (or equivalent standardized scale) during the current course of treatment.
- For treatment failure: documentation of two antidepressant trials including medication names, classes, doses, start/stop dates, and duration (≥ six weeks each) within the past 24 months.
- For intolerance: documentation of four antidepressant trials with evidence of major adverse interactions or intolerable side effects describing the reaction and medications involved.
Key Coverage Criteria
- Behavioral disorders: Not covered by this policy text — refer to the Optum Behavioral Clinical Policy titled 'Transcranial Magnetic Stimulation' at Optum Provider Express > Clinical Resources > Guidelines/Policies & Manuals > Behavioral Clinical Policies for coverage criteria for behavioral disorders.
- None explicitly covered in this Medical Policy for UnitedHealthcare Commercial and Individual Exchange plans. (The policy states that TMS for medical (i.e., non-behavioral) conditions is unproven and not medically necessary.)
- Initial treatment with rTMS, dTMS, or iTBS for adults aged ≥ 18 years.
- Confirmed diagnosis of severe Major Depressive Disorder (MDD), single episode or recurrent, per the most recent DSM.
- No diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder.
- PHQ-9 score ≥ 15 (or equivalent standardized scale) throughout the current course of treatment, indicating moderately severe to severe depression.
4 Active Policies
AMBETTER-CP.BH.200 — Transcranial Magnetic Stimulation for Treatment Resistant Major Depression
UHC-POL-transcranial-magnetic-stimulation — Transcranial Magnetic Stimulation for Treating Physical Health Conditions
UMR-POL-UMR-transcranial-magnetic-stimulation — Transcranial Magnetic Stimulation for Treating Physical Health Conditions
SUREST-POL-SUREST-transcranial-magnetic-stimulation — Transcranial Magnetic Stimulation for Treating Physical Health Conditions
Related Codes
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