Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (CPB 0469, reviewed 2026-07-17)

By 2026-07-17, the billing and clinical teams must: (1) Update prior authorization workflows to require documentation of two antidepressant trials from different classes (8+ weeks each at therapeutic doses) plus augmentation therapy (8+ weeks) for adults, or two antidepressant trials plus evidence-based psychotherapy or augmentation for adolescents aged 15-17; (2) Implement session limits in billing system to cap coverage at 30 treatment sessions plus 6 tapering sessions (36 total maximum), with manual review required for sessions beyond 36; (3) Add mandatory verification fields to prior authorization requests: FDA-cleared device confirmation, psychiatrist/PMHNP ordering and supervision documentation, standardized depression rating scale baseline and ongoing measurements (BDI, HDRS, or MADRS), member age verification (15+), and contraindication screening; (4) Update clinical documentation templates to require psychiatrist/PMHNP certification of direct supervision or properly trained personnel assignment; (5) Educate providers that retreatment requires documentation of prior 50% symptom reduction maintained for 2+ months and must occur >60 days after prior course termination; (6) Flag for denial any claims involving accelerated TMS, MRI-guided TMS, ketamine adjunctive use, or navigated TMS as experimental; (7) Update encounter forms to capture standardized depression rating scale scores at baseline and throughout treatment course. Failure to obtain proper prior authorization or document required criteria will result in claim denials.