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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

August 2013

TMS Now Covered with Prior Authorization 


Effective immediately, Harvard Pilgrim and its behavioral health partner Optum/United Behavioral Health (Optum/UBH) will begin covering medically necessary transcranial magnetic stimulation (TMS) for members in Harvard Pilgrim’s HMO, POS, or PPO products, provided a prior authorization is obtained and services are billed to Optum/UBH. To obtain a prior authorization, providers must submit required written information to Optum/UBH.

Harvard Pilgrim covers NeuroStar TMS Therapy as reasonable and medically necessary for members with documented major depression (single or recurrent episode), as defined by the presence of: diagnosis of major depression (DSM: 296.2–296.3; ICD-9: 296.3) by a licensed mental health professional (psychiatrist or nurse practitioner), as evidenced and documented by baseline HAMD24, MADRS, or other appropriate diagnostic tool that assesses the severity of depression, as well as one of the following:

  • Documented failure of at least four psychopharmacologic trials of adequate dose and duration (> 4 weeks) from two different agent classes in the current episode, or
  • Written documentation of an inability to tolerate psychopharmacologic agents as evidenced by four or more lifetime trials of agents with distinct side effects, or
  • Documented positive response (with appropriate standard rating scales and dates of service) to a previous TMS treatment.

Treatment is limited to 30 visits over seven weeks, followed by six taper treatments and one treatment planning service (90867) per course of treatment. For complete information, please see the Transcranial Magnetic Stimulation Medical Review Criteria. If you have any questions regarding TMS, please contact Optum/UBH at 888-777-4742.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

Annmarie Dadoly,
Editor

Kristin Edmonston,
Production Coordinator