Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder

(CP.BH.201)

Ambetter

Policy updates include:

• Added the following statement to the description section: “obsessive compulsive disorder (OCD) treatment with TMS delivers magnetic stimulation to the frontal brain structures and networks, targeting previously unreachable areas of the brain”
• In policy statement I.: changed the initial request of sessions from “20” to “30” sessions
• In criteria point I.A.: added the statement “per DSM-5-TR Criteria”
• Added criteria point I.B, “Administered using and Food and Drug Administration (FDA) cleared device and utilized in accordance with the FDA labeled indications such as but not limited to the following” and added a list of FDA approved devices
• In criteria point I.F.4.: Added the following statement “such as but not limited to the following”
• Removed the following statement from criteria point I.F.11.: “previously categorized as “Axis I” psychiatric disorders”. Added the following contraindication to I.F.12.: “No active suicidal ideation with intent”
• In policy statement II. replaced “request for an additional 10 sessions” with “request for taper of six final sessions”
• Added to criteria point II.A. “Criteria for initial dTMS treatment guidelines continues to be met”
• In criteria point II.B. replaced “25% reduction of OCD symptom severity” with “30% reduction of OCD symptom severity”
• In criteria point II.C. replaced “25% reduction in baseline severity scores” with “30% reduction in baseline severity scores”
• Added to criteria point IV.A.: “Criteria for initial dTMS treatment guidelines continues to be met”
• In criteria point IV.C. changed the responses percentage baseline drop from “50% drop from the baseline OCD scores” to “30% drop from the baseline OCD scores”
• Deleted criteria point IV. D.1-9. as this information is captured in IV.A

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

(CP.BH.200)

Ambetter

Policy updates include:

• In criteria statement I, added the frequency of sessions to (5 days a week, for six weeks)”
• In policy statement I:
  • In policy statement I. replaced “transcranial magnetic stimulation TMS” with “repetitive transcranial magnetic stimulation (rTMS)”
  • In policy statement I: added the statement: “and up to a total of 30 sessions of Theta Burst Stimulation (TBS)”
• Added to criteria point I.B. the statement regarding FDA cleared devices and included examples of current FDA approved devices
• Added criteria point I.D: “Planned use of standardized rating scale by TMS provider to monitor response during treatment”
• Removed the statement regarding augmentation from I.H.1: “At least two different trials of pharmacological classes were administered as an adequate course of antidepressants with a recognized standard therapeutic dose of at least six weeks duration during the current depressive episode (and within the last 24 months if the current episode exceeds 24 months of duration)”
• Added the statement to criteria point I.H.2.b. “… (and discontinuation)”
• Added contraindication to criteria point I.K.10: “Not experiencing acute active suicidal ideation with intent”
• Added a new policy statement II: It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that there is insufficient evidence to support the safety and efficacy of more than 30 sessions of TBS”