Prior Authorization
Anthem Prior Authorization for CPT 90867
Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment including initial, subsequent, and motor threshold re-determination sessions, and unlisted psychiatric service · Standard commercial plans
Source
Anthem clinical policyNot medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.
Clinical criteria
Anthem requires prior authorization for TMS for treatment-resistant MDD. Must document failure of at least 2 antidepressant medications from different classes at adequate doses for at least 8 weeks each, or documented intolerance. PHQ-9 score >=10 at baseline. Standard authorization: up to 36 sessions over 6-9 weeks. Psychiatric evaluation documenting treatment resistance required.
Documentation checklist
- ✓DSM-5 diagnosis of major depressive disorder
- ✓Documentation of 2+ failed antidepressant trials with drug names, doses, duration, and outcome
- ✓PHQ-9 score at baseline
- ✓TMS treatment plan specifying protocol, session count, and target site
- ✓Psychiatrist or psychiatric NP attestation of treatment resistance
Submission channels
Phone
1-800-274-77672026 Medicare rate for CPT 90867
CPT 90867 is not priced under the 2026 Medicare Physician Fee Schedule (status C) — drugs/biologicals price under ASP and lab tests under the CLFS. See the CPT 90867 code page for pricing detail.
How to submit the PA
- 1Verify the requirement against the current clinical policy linked above.
- 2Gather documentation: DSM-5 diagnosis of major depressive disorder, Documentation of 2+ failed antidepressant trials with drug names, doses, duration, and outcome, PHQ-9 score at baseline….
- 3Submit via phone, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Anthem require prior authorization for CPT 90867?
- Yes. Anthem requires prior authorization for CPT 90867 (Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment including initial, subsequent, and motor threshold re-determination sessions, and unlisted psychiatric service) under Standard commercial plans per its published clinical policy.
- What documentation does Anthem require for CPT 90867?
- DSM-5 diagnosis of major depressive disorder; Documentation of 2+ failed antidepressant trials with drug names, doses, duration, and outcome; PHQ-9 score at baseline; TMS treatment plan specifying protocol, session count, and target site; Psychiatrist or psychiatric NP attestation of treatment resistance
- What if Anthem denies the PA for CPT 90867?
- Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.
Other Anthem PA lookups
CPT 90867 prior authorization by payer
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