Medical Policy: 02.01.46 
Original Effective Date: January 2012 
Reviewed: August 2016 
Revised: August 2016 


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

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.

 

Repetitive transcranial magnetic stimulation (rTMS) was introduced as a 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, rTMS 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, post-partum depression, depression associated with Parkinson's disease, schizophrenia, migraine, spinal cord injury, tinnitus, and fibromyalgia.

 

The National Institute for Health and Care Excellence (NICE)
Current evidence suggests that there are no major safety concerns associated with transcranial magnetic stimulation (TMS) for severe depression. There is uncertainty about the procedure’ s clinical efficacy, which may depend on higher intensity, greater frequency, bilateral application and/or longer treatment durations than have appeared in the evidence to date. TMS should therefore be performed only in research studies designed to investigate these factors.


Based on Hayes meta-analysis (2014): Questions still remain about the standard treatment plan, the longevity, duration, the need for maintenance, and the actual effect of transcranial magnetic stimulation. Transcranial magnetic stimulation over sham transcranial magnetic stimulation, may not last beyond 2 or 3 weeks after the end of treatment. Low quality evidence suggested that transcranial magnetic stimulation may be at least as effective as electroconvulsive therapy under certain circumstances, but under other circumstances, electroconvulsive may be superior; this evidence is of low quality because of unexplained inconsistency in study results. Low quality evidence suggested that if transcranial magnetic stimulation has any effect on quality of life or function, it is very small. The review found insufficient evidence on the use of transcranial magnetic stimulation as maintenance therapy after acute response.

 

American Psychiatric Association

Released updated practice guidelines for the treatment of patients with major depressive disorder recommend that the treatment in the acute phase of MDD be aimed at inducing remission of the episode with a goal to return the patient to their baseline level of functioning.

 

Regulatory Status 

Transcranial Magnetic Stimulation (TMS) and Repetitive Transcranial Magnetic Stimulation (rTMS)

Devices for transcranial stimulation/repetitive transcranial stimulation have received clearance by the U.S. Food and Drug Administration (FDA) for diagnostic uses which include:

  • 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.
  • The Brainsway H-Coil Deep TMS device received FDAclearance in 2013. This device is indicated for the treatment of depression in patients who have failed to respond to antidepressant medications in their current episode of depression and is a broader indication than that of the NeuroStar® TMS, which specifies the failure of one course of antidepressant medication.
  • In 2013 the Cerena™ TMS device (Eneura Therapeutics) received De Novo marketing clearance for the acute treatment of pain associated with migraine headache with aura. Warnings, precautions, and contraindications include the following: The device is only intended for use by patients experiencing the onset of pain associated with a migraine headache with aura. The device should not be used on headaches due to underlying pathology or trauma. The device should not be used for medication overuse headaches..Safety and effectiveness have not been established in pregnant women, children under the age of 18, and adults over the age of 65.
  • A number of devices for CES have received marketing clearance through the FDA 510(k) process. The Alpha-Stim® CES device (Electromedical Products International) received marketing clearance in 1992 for the treatment of anxiety, insomnia, and depression.

Cranial Electrical Stimulation

Cranial electrical stimulation (CES) is a noninvasive method of delivering electrical stimulation, frequently in the home setting. Via a small, battery-operated device that delivers low level electrical stimulation (i.e., microcurrent) to the brain through electrodes that attach to the ear lobes via clips.  Treatment time generally ranges from 20-60 minutes daily, or as directed by the patient’s physician. Its proposed indications include, but may not be limited to, anxiety, depression, insomnia, fibromyalgia, Alzheimer’s Disease, and pain-related disorders.

 

Cranial electrical stimulation (also known as electrosleep, electrotherapeutic sleep, cerebral electrotherapy, transcranial electrotherapy, transcerebral electrotherapy, craniofacial electrostimulation, and electric cerebral stimulation) is being studied for the treatment of insomnia, anxiety and depression. Low levels of electrical current are applied via electrodes clipped onto the ear lobes or attached behind the ears. CES is thought to have a direct effect on the brain's limbic system, hypothalamus, and/or reticular activation system. It has also been suggested that CES may activate the parasympathetic autonomic nervous system by stimulating the vagus nerve.

 

Navigated Transcranial Magnetic Stimulation (nTMS)

A navigated TMS (nTMS) system received Naclearance from the FDA in 2009. The Nexstim eXimia Navigated Brain Stimulation System is marketed for use in pre-surgical planning of patients undergoing brain surgery. This system provides non-invasive functional mapping of the motor cortex using transcranial magnetic stimulation with standard MRI guidance. The studies to date on nTMS are limited by small sample size, limiting the validity of the study conclusions.


Prior Approval:

 

 

Not applicable.


Policy:

Transcranial Magnetic Stimulation


Transcranial magnetic stimulation and repeat transcranial magnetic stimulation of the brain is considered medically necessary when the following criteria is met for initial and single repeat treatment for a current acute depressive episode.

 

*Depressive episode is defined by the DSM V as :

  • Patient is age 18 through 64 years old.
  • Patient has a diagnosis of major depressive disorder
  • Patient has no psychotic symptoms. Evidence does not support use of TMS for major depression with psychotic features (psychotic depression). ECT is the treatment of choice in this situation.

Initial Treatment

  • Trial of at least 4 different antidepressants from at least 2 different pharmacological classes, this must have taken place in the current or previous depressive episode. OR
  • Trial of at least 3 different antidepressants from at least 2 different pharmacological classes AND augmenting agent was added to at least 1 trial, this must have taken place in the current or previous depressive episode.

It would be the expectation that step therapy as described in the Antidepressant Drug Policy is followed in regard to trial time and failure specifics of medications.

 

Treatment Specifics

  • If all criteria is met 36 standard repetitive TMS treatment sessions would be appropriate OR
  • If all criteria is met 44 deep TMS treatment sessions would be appropriate

Repeat Treatment

  • Success in alleviation of major depressive acute episode with previous TMS treatment

Maintenance Therapy
Currently the use of TMS as maintenance therapy is considered investigational Guidelines are necessary to define treatment course and maintenance appropriateness.  Information is lacking in overall standard of treatment and the lasting effects of participation in TMS.

 

Policy Guidelines

A major depressive episode is a period characterized by the symptoms of major depressive disorder: primarily depressed mood, and a loss of interest or pleasure in everyday activities, accompanied by other symptoms such as feelings of emptiness, hopelessness, anxiety, worthlessness, guilt and/or irritability, changes in appetite, problems concentrating, remembering details or making decisions, and thoughts of or attempts at suicide. This would have been present for 2 weeks or more and represent a change from previous functioning.

 

For both Initial and Repeat Treatments no contraindications should exist, including but not limited to the following:

  • No vagus nerve stimulator leads in the carotid sheath
  • No other implanted stimulators controlled by or that use electrical or magnetic signals
  • No conductive or ferromagnetic or other magnetic-sensitive metals implanted or imbedded in the head or neck within 30cm of TMS coil placement
  • No acute or chronic psychotic disorder
  • No seizure disorder or history of seizure disorder
  • No substance abuse at the time of TMS referral, including illegal or prescription substances
  • No dementia, including the inability to understand instructions or provide day-to-day consent
  • Inability to sit still for the treatments
  • No non-adherence with previous treatment for depression, including skipping medications,dosages, or treatments. 

Cranial Electrical Stimulation
Cranial electrical stimulation (CES) is investigational for all uses, such as but not limited to:

  • Headaches
  • Pain
  • Insomnia
  • Anxiety
  • Substance abuse treatment

Review of available literature reveals a lack of controlled clinical trials that prove the value and effectiveness of the procedure. As such, CES devices used in the home and clinical setting are investigational.

 

Navigated Transcranial Magnetic Stimulation (nTMS)
Navigated transcranial magnetic stimulation (nTMS) is considered investigational in preoperative treatment planning and diagnostic testing of motor function. There is limited evidence at this time to permit conclusions regarding the impact of this diagnostic testing on net health outcomes. Additional well-designed clinical studies with larger patient populations are required.



Procedure Codes and Billing Guidelines:

  • To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
  • 90867 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management
  • 90868 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session
  • 90869 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management
  • 0310T Motor function mapping using non-invasive navigated transcranial magnetic stimulation (nTMS) for therapeutic treatment planning, upper and lower extremity
  • E1399 Durable Medical Equipment, misc

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.
  • ECRI Institute. Repetitive Transcranial Magnetic Stimulation Using the NeuroStar System for Treating Major Depressive Disorder. Plymouth Meeting (PA): ECRI Health Technology Assessment Information ServiceExternal Site 2012 April. [Emerging Technology Evidence Report].
  • Picht T, Schulz J, Hamma M, Schmidt S, Suess O, Vajkoczy P. Assessment of the influence of navigated transcranial magnetic stimulation on surgical planning for tumors in or near the motor cortex. Neurosurgery. 2012 May;70(5):1248-56.
  • Pollak TA, Nicholson TR, Edwards MJ, David AS. A systematic review of transcranial magnetic stimulation in the treatment of functional (conversion) neurological symptoms. J Neurol Neurosurg Psychiatry. 2013 Jan 8. [Epub ahead of print]
  • Berlim MT Van den Eynde F, Jeff Daskalakis Z. Clinically meaningful efficacy and acceptability of low-frequency repetitive transcranial magnetic stimulation for treating primary major depression: A meta-analysis of randomized, double-blind and sham-controlled trials.
  • Hsu WY, Cheng CH, Liao KK, Lee IH, Lin YY. Effects of repetitive transcranial magnetic stimulation on motor functions in patients with stroke: a meta-analysis. Stroke 2012 Jul;43(7):1849-57.
  • Carpenter LL, Janicak PG, Aaronson ST, Boyadjis T, et al. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depress Anxiety. 2012 Jul.29(7):587-96.
  • Marlow NM, Bonilha HS, Short EB. Efficacy of transcranial direct current stimulation and repetitive transcranial magnetic stimulation for treating fibromyalgia syndrome: A systematic review. Pain PRact. 2012 May 28. [Epub ahead of print]   
  • California Technology Assessment Forum. June 17, 2009. Repetitive Transcranial Magentic Stimulation for Treatment Resistant Depression.  
  •  Canadian Agency for Drugs and Technologies in Health. January 15, 2013. Repetative Transcranial Magentic Stimulation for Specific Patient Populations: Clinical and Cost Effectiveness and Safety
  • UpToDateExternal Site Unipolar Depression in Adults: Treatment with Transcranial Magentic Simulation (TMS). Paul E. Holtzheimer M.D. Topic last updated September 9, 2013.
  • American Psychiatric AssociationExternal Site Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition 2010.
  • Kavirajan HC, Lueck K, Chuang K. Alternating current cranial electrotherapy stimulation (CES) for depression. Cochrane Database Syst Rev. Jul 8 2014;7:CD010521. PMID 25000907.
  • Barclay TH, Barclay RD. A clinical trial of cranial electrotherapy stimulation for anxiety and comorbid depression. J Affect Disord. Aug 2014;164:171-177. PMID 24856571.
  • Loo CK, Mitchell PB, Croker VM, Malhi GS, Wen W, Gandevia SC, Sachdev PS. Double-blind controlled investigation of bilateral prefrontal transcranial magnetic stimulation for the treatment of resistant major depression. Psychological Medicine. 2003 Jan;33(1):33-40.
  • Li H, Wang J, Li C, et al. Repetitive transcranial magnetic stimulation (rTMS) for panic disorder in adults. Cochrane Database Syst Rev. 2014;9:CD009083. PMID 25230088
  • Lefaucheur JP, Andre-Obadia N, Antal A, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol. Jun 5 2014. PMID 25034472
  • O'Connell NE, Wand BM, Marston L, et al. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst Rev. 2014;4:CD008208. PMID 24729198
  • Dunner DL, Aaronson ST, Sackeim HA, et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: durability of benefit over a 1- year follow-up period. J Clin Psychiatry. Sep 16 2014. PMID 25271871
  • Speer AM, et al. Antidepressant efficacy of high and low frequency rTMS at 110% of motor threshold versus sham stimulation over left prefrontal cortex. Brain Stimul 2014 Jan-Feb;7(1):36-41.
  • The National Institute for Health and Care Excellence (NICE) Transcranial magnetic stimulation for treating and preventing migraine. 2014 Jan.
  • Washington State Health Care Authority. Non-pharmacologic treatments for treatment-resistant depression. Final Evidence Report 2014 Feb 21.
  • DSM V
  • P. Lepping, C. Schonfeldt-Lecuona, R. S. Sambhi, S. V. N. Lanka, S. Lane, R. Whittington, S. Leucht, R. Poole, “A Systematic review of the clinical relevance of repetitive transcranial magnetic stimulation,” Acta Psychiatrica Scandinavica, 2014; 130:326-341.
  • Clinical practice guideline on the management of depression in adults.” Agency for Healthcare Research and Quality, 2016: Guideline Summary NGC-10760.
  • N. Philip, D. Dunner, S. Dowd, S. Aaronson, D. Brock, L. Carpenter, M. Demitrack, S. Hovav, P. Janicak, M. George, “Can Medication Free, Treatment-Resistant, Depressed Patients Who Initially Respond to TMS Be Maintained Off Medications?  A Prospective, 12-Month Multisite Randomized Pilot Study,” Brain Stimulation, 2016; 9:251-257.
  • Transcranial Magnetic Stimulation for the Treatment of Adults with PTSD, GAD or Depression:  A Review of Clinical Effectiveness and Guidelines,” Canadian Agency for Drugs and Technologies in Health, 2014; Rapid Response Report:  Summary with Critical Appraisal
  • N. Lipsman, T. Sankar, J. Downar, S. Kennedy, A. Lozano, P. Giacobbe, “Neuromodulation for treatment-refractory major depressive disorder,” Canadian Medical Association Journal, 2014; 186:33-39.
  • M. Berlim, F. Van den Eynde, Z. Daskalakis, “EFFICACY AND ACCEPTABILITY OF HIGH FREQUENCY REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (rTMS) VERSUS ELECTROCONVULSIVE THERAPY (ECT) FOR MAJOR DEPRESSION:  A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED TRIALS,” Depression and Anxiety, 2013; 30:614-623.
  • B. Micallef-Trigona, “Comparing the Effects of Repetitive Transcranial Magnetic Stimulation and Electroconvulsive Therapy in the Treatment of Depression:  A Systematic Review and Meta-Analysis,” Depression Research and TreatmentExternal Site 
  • A. Sarker, R.C. Kadosh, “Transcranial Electrical Stimulation and Numerical Conditioning,” Can J Exp Psychol. 2016 Mar;70(1):41-58. doi: 10.1037/cep0000064.
  • G. Grammer, A. Kuhle, C. Clark, M. Dretsch, K. Williams, J. Cole, “Severity of depression predicts remission rates using transcranial magnetic stimulation,” Frontiers in Psychiatry, 2015; Volume 6 Article 114.
  • Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” Health Quality Ontario, Ontario Health Technology Assessment Series, 2016; Vol. 16, No. 5.
  • Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: An Economic Analysis,” Health Quality Ontario, Ontario Health Technology Assessment Series, 2016; Vol. 16, No. 6.
  • P. Janicak, M. Dokucu, “Transcranial magnetic stimulation for the treatment of major depression,” Neuropsychiatric Disease and Treatment, 2015:11 1549-1560.
  • A. Mantovani, M. Pavlicova, D. Avery, A. Nahas, W. McDonald, C. Wajdik, P. Holtzheimer, M. George, H. Sackeim, S. Lisanby, “Long-Term Efficacy of Repeated Daily Prefrontal Transcranial Magnetic Stimulation (TMS) In Treatment-Resistant Depression,” PsychiatryOnline, Depression: Challenges and Treatments, 2016; Volume 14 Issue 2, pp. 277-282.
  • Nonpharmacologic Treatments for Treatment-Resistant Depression,” Washington State Health Care Authority, Health Technology Assessment, Final Evidence Report, 2014.
  • E. Wassermann, T. Zimmermann, “Transcranial Magnetic Brain Stimulation: Therapeutic Promises and Scientific Gaps,” Pharmacol Ther, 2012; 133(1): 98-107.
  • A. Mantovani, M. Pavlicova, D. Avery, A. Nahas, W. McDonald, C. Wajdik, P. Holtzheimer, M. George, H. Sackeim, S. Lisanby, “Long-Term Efficacy of Repeated Daily Prefrontal Transcranial Magnetic Stimulation (TMS) In Treatment-Resistant Depression,” PsychiatryOnline, Depression: Challenges and Treatments, 2016; Volume 14 Issue 2, pp. 277-282.
  • L. Vallejo-Torres, I. Castilla, N. Gonzalez, R. Hunter, P. Serrano-Perez, L. Perestelo-Perez, “Cost-effectiveness of electroconvulsive therapy compared to repetitive transcranial magnetic stimulation for treatment-resistant severe depression: a decision model,” Psychological Medicine, 2015; 45: 1459-1470.
  • Demitrack MA, Thase ME, “Clinical significance of transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant depression: synthesis of recent data,” Psychopharmacol Bull, 2009; 42(2): 5-38.
  • P. Holtzheimer, “Unipolar depression in adults: Treatment with transcranial magnetic stimulation (TMS), UpToDate, 2014; Topic 14641 Version 7.0.
  • Dunner D.L., Aaronson S.T., et al., (2014) A Multisite, Naturalistic, Observational Study of Transcranial Magnetic Stimulation (TMS) for Patients with Pharmacoresistant Major Depression: Durability of Benefit Over a One-Year Follow-Up Period. J Clin Psychiatry. 2014 Sep 16.
  • Fitzgerald PB, Benitez J, de Castella AR, Brown TL, Daskalakis ZJ, Kulkarni J. (2006) Naturalistic Study of the Use of  Transcranial Magnetic Stimulation in the Treatment of Depressive Relapse. Aust N Z J Psychiatry, 40(9):764–768
  • Gaynes BN, Lux L, Lloyd S, Hansen RA, Gartlehner G, Thieda P, Jonas D, Brode S, Swinson Evans T, Crotty K, Viswanathan M, Lohr KN. Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults. Comparative Effectiveness Review No. 33. (Prepared by RTI International-University of North Carolina [RTI-UNC] Evidence-Based Practice Center under Contract No. 290-02-0016I.) AHRQ Publication No. 11-EHC056-EF. Rockville,MD: Agency for Healthcare Research and Quality. September 2011. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfmExternal Site 
  • Gaynes BN, Lloyd SW, Lux L, Gartlehner G, Hansen RA, Brode S, Jonas DE, Swinson Evans T, Viswanathan M, Lohr KN. (2014) Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and meta-analysis. J Clin Psychiatry. 2014 May;75(5):477-89
  • George, M. S., Lisanby, S. H., et al. (2010) Daily Left Prefrontal Transcranial magnetic Stimulation Therapy for Major Depressive Disorder: A Sham-Controlled Randomized Trial. Arch Gen Psychiatry 76(5): 507 - 516.
  • Carpenter, LL, Janicak, PG, Aaronson, ST, Boyadjis, T, Brock, DG, Cook, IA, Dunner, DL, Lanocha, K, Solvason, HB,  Demitrack, MA. (2012) Transcranial Magnetic Stimulation (TMS) for Major Depression: A Multisite, Naturalistic, Observational Study of Acute Treatment Outcomes in Clinical Practice. Depress Anxiety, 29(7):587- 596.
  • Cohen RB, Boggio PS, Fregni F: Risk factors for relapse after remission with repetitive transcranial magnetic stimulation for the treatment of depression. Depress Anxiety 2009; 26(7):682–688.
  • Dannon PN, Dolberg OT, Schreiber S, Grunhaus L: (2002) Three and six-month outcome following courses of either ECT or TMS in a population of severely depressed individuals—Preliminary report. Biol Psychiatry; 51;687–690
  • Demirtas-Tatlidede A, Mechanic-Hamilton D, Press DZ, Pearlman C, Stern WM, Thall M, Pascual-Leone A: (2008) An open-label, prospective study of repetitive transcranial magnetic stimulation (TMS) in the long-term treatment of refractory depression: reproducibility and duration of the anti-depressant effect in medication-free patients. J Clin Psychiatry;  69:930–934
  • Guse, B, Falkai, P, Wobrock, T. (2010) Cognitive effects of high-frequency repetitive transcranial magnetic stimulation:  a systematic review.  J Neural Transm 117: 105-122.
  • Janicak, P.G., O’Reardon, J.P., et al. (2008) Transcranial Magnetic Stimulation in the treatment of major depression: A comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment. Journal of Clinical Psychiatry 69, 222-232
  • Janicak, PG, Nahas, Z, Lisanby, SH, Solvason, HB, Sampson, SM, McDonald, WM,  Marangell, LB, Rosenquist, P, McCall, WV, Kimballl, J, O’Reardon, JP, Loo, C, Husain, MH, Krystal, A, Gilmer, W, Dowd, SM, Demitrack, MA, Schatzberg, AF. (2010) Durability of Clinical Benefit With Transcranial Magnetic Stimulation (TMS) in the Treatment of Pharmacoresistant Major Depression: Assessment of Relapse During a Six-Month, Multisite, Open- Label Study. Brain Stimulation, 3:187-199.
  • Janicak, PG, Dunner, DL, Aaronson, ST, Carpenter, LL, Boyadjis, TA, Brock, DG, Cook, IA, Lanocha, K, Solvason, HB,  Bonneh-Barkay, D, Demitrack, MA. (2013) Transcranial Magnetic Stimulation (TMS) for Major Depression: A  Multisite, Naturalistic, Observational Study of Quality of Life Outcome Measures in Clinical Practice, CNS Spectrums, August:1-11.
  • Kennedy, SH, Milev, R, Giacobbe, P, Ramasubbu, R, Lam, RW, Parikh, SV, Patten, SB, Ravindran, AV. (2009) Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive  disorder in adults. IV. Neurostimulation therapies. J Aff Disorders 117:S44-S53.
  • Mantovani, A, Pavlicova, M, Avery, D, Nahas, Z, McDonald, WM, Wajdik, CD, Holtzheimer, PE, George, MS, Sackeim,  HA, Lisanby, SH. Long-Term Efficacy of Repeated Daily Prefrontal Transcranial Magnetic Stimulation (TMS) in Treatment-Resistant Depression. (2012) Depression and Anxiety, 00:1-8
  • O'Reardon, J.P., Solvason, H.B., et al. (2007) Efficacy and safety of Transcranial Magnetic Stimulation in the acute treatment of major depression: A multisite randomized controlled trial. Biol Psychiatry, 62:1208-1216.
  • Rush AJ, Trivedi MH, Nierenberg AA, Stewart JW, Warden D, Niederehe G, Thase M, Lavori PW, Lebowitz BD, McGrath PJ,  Rosenbaum JF. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163:1905–1917.
  • Schlaepfer, T. E., M. S. George, et al. (2009). WFSBP Guidelines on Brain Stimulation Treatments in Psychiatry. The  World Journal of Biological Psychiatry 1: 1-17.
  • Slotema CW, Blom JD, Hoek HW, Sommer IE. Should we expand the toolbox of psychiatric treatment methods to include repetitive transcranial magnetic stimulation (TMS): A meta-analysis of the efficacy of TMS in psychiatric disorders. J Clin Psychiatry. 2010;71(7): 873-884.

Policy History:

  • August 2016 - Annual Review, Policy Revised
  • October 2015 - Annual Review, Policy Revised
  • November 2014 - Annual Review, Policy Revised
  • July 2014 - Interim Review, Policy Renewed
  • January 2014 - Annual Review, Policy Revised
  • January 2013 - Annual Review, Policy Revised
  • January 2012 - Literature Review, New Policy

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.