Download Transcranial Magnetic Stimulation (TMS) for

 Transcranial Magnetic Stimulation (TMS) for Depression
Fax to: 616.975.0249
Member information
Last name _________________________________
Priority Health ID # __________________________
First name __________________________
Date of birth __________________________
Provider name ______________________________
Service address _____________________________
__________________________________________
Provider tax ID ________________________
Phone number ________________________
Contact name ________________________
For all TMS Requests, clinical record must be faxed with this form.
Clinical must include supporting documentation that patient is receiving psychiatric. For Medicare
members please also include psychotherapy services. For TMS medical policy criteria information, go to:
http://www.priorityhealth.com/provider/manual/auths/~/media/documents/medical-policies/91563.pdf
Axis I diagnosis ____________________________________________________________
List all medications:
SSRI _____________________________________
SSNI _______________________________
TCAs _____________________________________
MAOIs ______________________________
Check all absolute contraindications
 Seizure disorder or any history of seizures (except those induced by ECT or isolated febrile seizures
in infancy without subsequent treatment or recurrence)
 Space occupying brain lesion
 Evidence of increased intracranial pressure
 Presence of intracranial devices (e. g. CSF shunts, aneurysm clips, cochlear/otologic implants, deep







brain stimulation leads)
Vagus nerve stimulator leads (with or without IPG)
Facial tattoos with metallic ink
Carotid or cerebral stents
Ferromagnetic ocular implants
Magnetically activated dental implants
Pellets, bullets or metallic fragments < 30 cm from coil
None of the above
Check all relative contraindications:
 Dementia and other degenerative neurologic conditions, e. g. Parkinson's Disease, multiple sclerosis;
 Unstable medical conditions;
 Chronic or acute psychotic disorder, e. g. schizophrenia, schizophreniform disorder, schizoaffective





disorder
Serious co-morbid psychiatric conditions, e. g. psychotic depression, active substance abuse;
History of cerebrovascular accident
Implantable automatic defibrillator of cardiac pacemaker
History of significant head injury (loss of consciousness > 5 min and/or hospitalization)
None of the above
Please review TMS policy for limitations, exclusions, and provider requirements.
Please include validated, evidence-based depression monitoring tool such as HAM-D,
MADRS or QIDS, IDS-SR.
Priority Health office use only: Received date_______________ Decision date____________ Date(s) of evaluation(s) (if available) 7364A 03/2016