REPETITIVETRANSCRANIALMAGNETICSTIMULATIONREQUESTFORM

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InNetwork / OutofNetwork
MEMBERNAME: / DOB: / GENDER:
HEALTHPLAN: / POLICY#:
DateandTimeofRequest:
TreatingClinician/Facility:
Ifthe treatingclinicianisnotmakingthis request,hasthetreatingclinicianbeennotified?☐Yes☐No / Yes / No
Phone#: / NPI/TIN#:
Servicing Clinician/Facility:
Phone#: / NPI/TIN#:
INITIAL TREATMENT
1.Hasaconfirmeddiagnosisofseveremajordepressivedisorder(MDD)singleorrecurrentepisode
F32.2 / MajorDepressiveDisorder,SingleEpisode,Severe(WithoutPsychoticFeatures)
F33.3 / MajorDepressiveDisorder,RecurrentEpisode,Severe(WithoutPsychoticFeatures)
Pre-treatmentratingscale: / GDS / PHQ-9 / BDI / HAM-D / MADRS / QIDS / IDS-SR
AND
2.Oneormoreofthefollowing:
Resistancetotreatmentwithpsychopharmacologicagentsasevidencedbyalackofaclinicallysignificantresponsetofouradequatetrials
ofatleastsixweeksdurationofpsychopharmacologicagentsinthecurrentdepressive episodefromatleasttwo differentagentclassesasdocumentedbystandardizedratingscalesthatreliablymeasuredepressivesymptoms(GDS,PHQ-9,BDI,HAM-D,MADRS,QIDS,orIDS-SR);or
Inabilitytotoleratepsychopharmacologicagentsasevidencedbyfourtrialsofpsychopharmacologicagentsfromatleasttwodifferentagent classes(atleastoneofwhichisintheantidepressantclass),withdistinctsideeffects;or
HistoryofresponsetorTMSinapreviousdepressiveepisode;or
Currentlyreceivingelectroconvulsivetherapy (ECT); or
CurrentlyconsideringECT;rTMSmaybeconsideredasalessinvasivetreatmentoption
*Noteforreference:Remissionistypicallydefinedbythefollowingmeasurementscores:BeckDepressionScale(BDI)scoreof<9,HamiltonDepressionRatingScale(HAM-D)scoreof<8ontheHAM-D-17and<11ontheHAM-D-24,Montgomery-AsbergDepressionRatingScale(MADRS)scoreof
10,PatientHealthQuestionnaire(PHQ-9)scoreof5
AND
3.Atrialofanevidence-basedpsychotherapyknowntobeeffectiveinthetreatmentofMDDofanadequatefrequencyandduration
withoutsignificantimprovementindepressivesymptomsasdocumentedbystandardizedratingscalesthatreliablymeasuredepressivesymptoms(GDS,PHQ-9,BDI,HAM-D,MADRS,QIDSorIDS-SR).
AND
4. An order written by a psychiatrist (MDor DO) whohas examined the patient and reviewed the record. The physician will have
experience in administering TMS therapy. The treatment shall be given under direct supervision of this physician.

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PotentialContraindications(pleaseselectallapplicablecontraindicationsthepatienthasfromthelistbelow):
Seizuredisorder or any history of seizures(except those induced by ECT or isolated febrileseizures in infancy without subsequent treatment or recurrence)
Presenceofacuteorchronicpsychoticsymptomsordisordersinthecurrentdepressiveepisode
Neurologicalconditionsthatincludeepilepsy,cerebrovasculardisease,dementia,increasedintracranialpressure,historyofrepetitiveorsevere
headtrauma,orprimaryorsecondarytumorsinthecentralnervoussystem
Presenceofanimplantedmagnetic-sensitivemedicaldevicelocatedlessthanorequalto30cmfromtheTMSmagneticcoilorotherimplanted metalitemsincludingbutnotlimitedtoacochlearimplant,implantedcardiacdefibrillator(ICD),pacemaker,vagusnervestimulation(VNS),ormetalaneurysmclipsorcoils,staples,orstents
Note:DentalamalgamfillingsarenotaffectedbythemagneticfieldandareacceptableforusewithTMS.
PriorfailedtrialofanadequatecourseoftreatmentwithECTorvagusnervestimulation(VNS)forMajorDepressiveDisorder
Thepatientiscurrently: / pregnantor / nursing
Thepatienthasacurrentsuicideplanorrecentsuicideattempt
Currentactivehistoryof(“x” for thosethatapply): / EatingDisorder / PsychoticDisorder,includingSchizoaffectiveDisorder
BipolarDisorder
Historyof(“x” forthosethatapply): / SubstanceAbuse / ObsessiveCompulsiveDisorder / Post-TraumaticStressDisorder
RETREATMENT
1.PatientmettheguidelinesforinitialtreatmentANDmeets guidelinescurrently.
AND
2.Subsequentlydevelopedrelapseofdepressivesymptoms
AND
3.Responded topriortreatments asevidencedbyagreaterthan50%improvement instandardratingscalemeasurements for depressivesymptoms(e.g.,GDS,PHQ-9,BDI,HAM-D,MADRS,QIDSorIDS-SRscores).
Post-treatmentratingscale: / GDS / PHQ-9 / BDI / HAM-D / MADRS / QIDS / or IDS-SR
Datesofinitialtreatment,ifknown:
TREATMENTTYPE(S)REQUESTED
FDA-approvedTMSdevicetobeusedforthefollowingtreatment:
90867 / THERAPEUTICREPETITIVETRANSCRANIALMAGNETICSTIMULATION(TMS)TREATMENT—INITIAL,INCLUDINGCORTICALMAPPING,MOTORTHRESHOLDDETERMINATION,ANDDELIVERYANDMANAGEMENT
90868 / THERAPEUTICREPETITIVETRANSCRANIALMAGNETICSTIMULATION(TMS)TREATMENT—SUBSEQUENTDELIVERYANDMANAGEMENT,PERSESSION
90869 / THERAPEUTICREPETITIVETRANSCRANIALMAGNETICSTIMULATION(TMS)TREATMENT—SUBSEQUENTMOTORTHRESHOLDREDETERMINATIONWITHDELIVERYANDMANAGEMENT

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