Humana Military uses this four-page request, which opens with a one-page checklist, for TRICARE East authorization of transcranial magnetic stimulation for depression. The provider documents diagnoses, current medications, evaluations such as the BDI or PHQ-9, psychotherapy, prior TMS or ECT, and failed antidepressant trials by class, then lists the device, location, CPT codes and contraindication screening.
The treating psychiatrist or TMS provider completes all fields, including the referring provider, military hospital or clinic, servicing facility and provider credentials, and signs the request.
Download the current version from the source each time; forms change without notice.
Transcranial Magnetic Stimulation (TMS) treatment request
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Humana Military's form asks for diagnoses, current medications, evaluations such as the BDI or PHQ-9 with scores, psychotherapy history, prior TMS or ECT and outcomes, failed antidepressant trials by class, desired observable outcomes, the beneficiary's agreement with treatment goals, and the device, location and CPT 90867 to 90869 units.
Neurological conditions such as epilepsy or a CNS tumor, metal in or around the head, vagus nerve stimulators or physiologically controlled implants such as pacemakers or cochlear implants, past or present seizure disorder, excessive alcohol or illicit substance use in the past 30 days, severe cardiovascular disease, and pregnancy or breastfeeding.
Yes. The service request section lets the provider choose inpatient, outpatient or a combination, and mark whether it is an initial request with frequency and administration, or a concurrent continued treatment request with past frequency, new frequency and duration.