|
Medical Policy: 02.01.46
Original Effective Date: January 2012
Reviewed:
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Transcranial magnetic stimulation (TMS) is a noninvasive method of delivering electrical stimulation to the brain. A magnetic field is delivered through the skull, where it induces electric currents that affect neuronal function. Repetitive TMS (rTMS) is being evaluated as a treatment of depression and other psychiatric/neurologic brain disorders.
Transcranial magnetic stimulation (TMS) was first introduced in 1985 as a new method of noninvasive stimulation of the brain. The technique involves placement of a small coil over the scalp; passing a rapidly alternating current through the coil wire, which produces a magnetic field that passes unimpeded through the scalp and bone, resulting in electrical stimulation of the cortex. TMS was initially used to investigate nerve conduction; for example, TMS over the motor cortex will produce a contralateral muscular-evoked potential. The motor threshold, which is the minimum intensity of stimulation required to induce a motor response, is empirically determined for each individual by localizing the site on the scalp for optimal stimulation of a hand muscle, then gradually increasing the intensity of stimulation. The stimulation site for treatment is usually 5 cm anterior to the motor stimulation site.
Interest in the use of TMS as a treatment for depression was augmented by the development of a device that could deliver rapid, repetitive stimulation. Imaging studies had shown a decrease in activity of the left dorsolateral prefrontal cortex (DLPFC) in depressed patients, and early studies suggested that high frequency (e.g., 5–10 Hz) TMS of the left DLPFC had antidepressant effects. Low frequency (1–2 Hz) stimulation of the right DLPFC has also been investigated. The rationale for low frequency TMS is inhibition of right frontal cortical activity to correct the interhemispheric imbalance. A combination approach (bilateral stimulation) is also being explored. In contrast to electroconvulsive therapy, TMS does not require anesthesia and does not induce a convulsion.
TMS is also being studied as a treatment for a variety of other disorders including alcohol dependence, Alzheimer’s disease, neuropathic pain, obsessive-compulsive disorder, and post-partum depression, depression associated with Parkinson’s disease, schizophrenia, migraine, spinal cord injury, tinnitus, and fibromyalgia.
Devices for transcranial stimulation have received clearance by the U.S. Food and Drug Administration (FDA) for diagnostic uses. One device, NeoPulse (Neuronetics, Atlanta, GA), received approval in Canada, Israel, and the United States as a therapy for depression. Initially examined by the FDA under a 510(k) application, the NeoPulse, now known as NeuroStar® TMS, received clearance for marketing as a “De Novo” device in 2008. NeuroStar® TMS is indicated for the treatment of patients with depression who have failed one 6-week course of antidepressant medication.
 Top
Prior Approval:
Not applicable.
Top
Policy:
Transcranial magnetic stimulation of the brain is considered investigational as a treatment of depression and other psychiatric/neurologic disorders such as schizophrenia or migraine headaches.
Evidence on TMS for depression is insufficient to permit conclusions regarding the effect of this technology on health outcomes. The literature on TMS for treatment-resistant depression (variably defined) includes a number of double-blind randomized sham-controlled short-term trials. Results of these trials show mean improvements of uncertain clinical significance across groups as a whole. The treatment protocols are time intensive, and the patients most likely to benefit from treatment are not currently known. Importantly, a number of open issues need to be addressed before this procedure is widely implemented. In addition to determining which of the locations and treatment parameters examined to date are most effective, further research is needed to guide the number of sessions needed to elicit a clinically significant response, to determine whether the response is durable with or without anti-depressant medications, and to provide some information about whether, and what types of, maintenance treatments are needed. The available studies do not establish that TMS is as good as available alternatives, as the vast majority of trials do not compare TMS to alternative active treatments. Alternative active treatments include a variety of different medication regimens and psychologic talk therapy, both of which have demonstrated efficacy.
Top
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 90867 Therapeutic repetitive transcranial magnetic stimulation treatment; planning
- 90868 delivery and management, per session.
Top
Selected References:
- Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Transcranial magnetic stimulation for depression. TEC Assessments 2011; Volume 26, Tab 3.
- Schutter DJ. Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis. Psychol Med 2009; 39(1):65-75.
- Lam RW, Chan P, Wilkins-Ho M et al. Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and metaanalysis. Can J Psychiatry 2008; 53(9):621-31.
- O’Reardon JP, Solvason HB, Janicak PG et al. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry 2007; 62(11):1208-16.
- George MS, Lisanby SH, Avery D et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatry 2010; 67(5):507-16.
- Rossini D, Lucca A, Zanardi R et al. Transcranial magnetic stimulation in treatment-resistant depressed patients: a double-blind, placebo-controlled trial. Psychiatry Res 2005; 137(1-2): 1-10.
- Lisanby SH, Husain MM, Rosenquist PB et al. Daily left prefrontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. Neuropsychopharmacology. 2009 Jan; 3492): 522-34. Epub 2008 Aug 13.
- Triggs WJ, Ricciuti N, Ward HE et al. Right and left dorsolateral pre-frontal rTMS treatment of refractory depression: a randomized, sham-controlled trial. Psychiatry Res. 2010 Aug 15; 178(3):467-74. Epub 2010 Jun 18.
- Janicak PG, Nahas Z, Lisanby SH et al. Durability of clinical benefit with transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistent major depression: assessment of relapse during a 6-month, multisite, open-label study. Brain Stimul. 2010 Oct; 3(4):187-99. Epub 2010 Aug 11.
- Dell’osso B, Camuri G, Castellano F et al. Meta-review of Meta-analytic studies with repetitive transcranial magnetic stimulation (rTMS) for the treatment of major depression. Clin Pract Epidemiol Ment Health. 2011; 7:167-77. Epub 2011 Oct 26.
- ECRI Institute. Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for treatment resistant depression. Plymouth Meeting (PA): ECRI Institute; 2011 Dec 20.
- Agency for Healthcare Research and Quality (AHRQ). Nonpharmacologic interventions for treatment-resistant depression in adults. 2011 Sep 23.
- Herbsman T, Avery D, Ramsey D et al. More lateral and anterior prefrontal coil location is associated with better repetitive transcranial magnetic stimulation antidepressant response. Biol Psychiatry. 2009 Sep 1; 66(5): 509-15. Epub 2009 Jul 9.
Top
Policy History:
Date Reason Action
January 2012 Literature review New policy
Top
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
|
 |
