BlueCross BlueShield of Tennessee Medical Policy Manual

Transcranial Magnetic Stimulation (TMS)

DESCRIPTION

Transcranial magnetic stimulation (TMS) is a noninvasive method of delivering electrical stimulation to the brain at various frequencies or stimulus intensities. When the device delivers a rapid repetitive stimulation, it is referred to as repetitive transcranial magnetic stimulation (rTMS). Conventional rTMS is a repetition of individual pulses at a pre-set interval (train of pulses), whereas theta-burst rTMS is a repetition of short bursts of pulses at a pre-set interval (train of bursts). Stimulation can either be delivered unilaterally, over the left or right dorsolateral prefrontal cortex, or bilaterally over both cortices. Bilateral stimulation may be done sequentially or simultaneously.

Repetitive transcranial magnetic stimulation has been evaluated for treatment-resistant major depression and is proposed to relieve symptoms by stimulating nerve cells in the brain believed to be associated with mood regulation. A treatment course is usually 36 treatment sessions, beginning with one session daily five times per week for six weeks and tapering to three sessions the next week, two sessions the next week, and then one session the following week. The treatment course may be repeated after a 3 month cessation period if needed. Clinical trials show that about 1/3 of individuals treated will experience a return of symptoms.

TMS devices (repetitive and single-pulse) are also being evaluated for other psychiatric/neurologic disorders (e.g., alcohol dependence, Alzheimer disease, post-traumatic stress disorder, panic disorder, obsessive-compulsive disorder, epilepsy, migraine).

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

For conditions other than treatment-resistant major depression, the evidence is insufficient to determine if treatment with repetitive TMS leads to improved outcomes. Currently, FDA approved devices are indicated for adult use only (e.g. NeuroStar®, Brainsway™ H-Coil Deep TMS, Rapid Therapy System, Mag Vita TMS Therapy® system, Mag Vita TMS Therapy System with Theta Burst Stimulation, Neurosoft TMS).  

SOURCES

BlueCross BlueShield Association. Evidence Positioning System (10:2018). Transcranial magnetic stimulation as a treatment of depression and other psychiatric/neurologic disorders (2.01.50). Retrieved July 1, 2019 from https://www.evidencepositioningsystem.com/. (45 articles and/or guidelines reviewed)

CMS.gov: Centers for Medicare & Medicaid Services. Palmetto, GBA. (2018, March). Local Coverage Determination (LCD): Repetitive transcranial magnetic stimulation (rTMS) in adults with treatment resistant major depressive disorder (L34869). Retrieved July 26, 2018 from https://www.cms.gov.  

Croarkin, P.  Nakonezny, P., Wall, C.  Murphy, L. Sampson, S.  Frye, M., et al. (2015). Transcranial magnetic stimulation potentiates glutamatergic neurotransmission in depressed adolescents. Psychiatry Research: Neuroimaging, 247, 25-33. (Level 3 evidence)

Donaldson, A., Gordon, M., Melvin, G., Barton, D., and Fitzgerald, P. (2013). Addressing the needs of adolescents with treatment resistant depressive disorders: a systematic review of rTMS. Brain Stimulation, 7, 7-12. (Level 4 evidence)

Janicak, P. and Dokucu, M. (2015). Transcranial magnetic stimulation for the treatment of major depression. Neuropsychiatric Disease and Treatment, 11, 1549-1560. (Level 2 evidence)

Kelly, M., Oliveira-Maia, A., Bernstein, M., Stern, A., Press, D., Pascual-Leone, A., et al. (2017). Initial response to transcranial magnetic stimulation treatment for depression predicts subsequent response. Journal of Neuropsychiatry and Clinical Neuroscience, 29, 179-182. (Level 4 evidence)

Krishnan, C., Santos, L., Peterson, M., and Ehingeraa, M., (2015) Safety of noninvasive brain stimulation in children and adolescents. Brain Stimulation, 8 (1), 76-87. (Level 4 evidence)

Lan, L., Zhang, X., Li, X., Rong, X., & Peng, Y. (2017). The efficacy of transcranial magnetic stimulation on migraine: a meta-analysis of randomized controlled trials. The Journal of Headache and Pain, 18, 86. (Level 2 evidence)

National Institute for Health and Clinical Excellence (NICE). (2014, January). Repetitive transcranial magnetic stimulation for depression. Retrieved July 12, 2017 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2014, January). Transcranial magnetic stimulation for treating and preventing migraine. Retrieved March 20, 2015 from http://www.nice.org.uk.

Pedapati, E., Gilbert, D., Horn, P., Huddleson, D., Laue, C., Shahana, N., et al. (2015). Effects of 30 Hz theta burst transcranial magnetic stimulation on the primary motor cortex in children and adolescents. Frontiers in Human Neuroscience, Vol. 9, Article 91. (Level 4 evidence)

Rapinesi, C., Bersani, F., Kotzalidis, G., Imperatori, C., Casale, A., DiPietro, S., et al. (2015). Maintenance deep transcranial magnetic stimulation sessions are associated with reduced depressive relapses in patients with unipolar or bipolar depression. Frontiers in Neuroscience, Vol 6, Article 16. (Level 4 evidence)

Sahu, A.K., Sinha, V.K., & Goyal, N. (2019). Effect of adjunctive intermittent theta-burst repetitive transcranial magnetic stimulation as a prophylactic treatment in migraine patients: a double-blind sham-controlled study. Indian Journal of Psychiatry, 61 (2), 139-145. (Level 2 evidence)

U. S. Food and Drug Administration. (2008, December). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K083538 (NeuroStar®). Retrieved September 12, 2014 from http://www.accessdata.fda.gov. 

Winifred S. Hayes, Inc. Medical Technology Directory. (2014, March). Transcranial magnetic stimulation for treatment-resistant depression.  Retrieved May 16, 2016 from www.Hayesinc.com/subscribers. (120 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2016, December; last updated November 2018). Comparative effectiveness review of high-frequency left repetitive transcranial magnetic stimulation versus other neurostimulation approaches to treatment-resistant depression. Retrieved July 2, 2019 from www.Hayesinc.com/subscribers. (66 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2016, November; last update search November 2018). High-frequency left repetitive transcranial magnetic stimulation for treatment-resistant major depressive disorder. Retrieved July 3, 2019 from www.Hayesinc.com/subscribers. (78 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2016, September; last update search September 2018). Low-frequency right repetitive transcranial magnetic stimulation for treatment-resistant major depressive disorder. Retrieved July 26, 2018 from www.Hayesinc.com/subscribers. (30 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2019, March). Transcranial magnetic stimulation for the treatment of obsessive-compulsive disorder.  Retrieved July 3, 2019 from www.Hayesinc.com/subscribers. (56 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  12/21/2016

MOST RECENT REVIEW DATE:  10/31/2019    

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.