Update on NYS Medicaid Coverage for Therapeutic Transcranial Magnetic Stimulation (TMS)

Effective November 1, 2025, and in accordance with New York State Department of Health (DOH) guidance, Healthfirst will provide coverage for Therapeutic Transcranial Magnetic Stimulation (TMS) for eligible Medicaid, Medicaid Advantage Plus (MAP), and Health and Recovery Plan (HARP) members diagnosed with Treatment-Resistant Major Depressive Disorder (MDD).

TMS is a non-invasive brain stimulation therapy that uses magnetic pulses to activate specific regions of the brain associated with mood regulation. This therapy is used to improve symptoms of major depressive disorder in members who have not responded to conventional antidepressant treatments.

Coverage and Eligibility Criteria

TMS is covered when all of the following criteria are met:

• The member is 18 years of age or older.
• The member has a diagnosis of Major Depressive Disorder (MDD) as defined by ICD-10 codes:
  • F32.2 – Major depressive disorder, single episode, severe, without psychotic features.
  • F33.2 – Major depressive disorder, recurrent, severe, without psychotic features.
• The member meets treatment-resistant depression criteria, defined as failure to achieve a satisfactory clinical response following at least two trials of antidepressants at adequate dosage, duration, and adherence.
• The diagnosis has been clinically confirmed, and other etiologies that may interfere with medication effectiveness have been ruled out.
• TMS is not being used as a first-line therapy for depression.
• TMS must be performed by a psychiatrist who has completed specialized training and certification in TMS administration.

Clinical Oversight

All non-approval recommendations for TMS services cases where the initial review determines that medical necessity criteria are not met, will be reviewed by a Healthfirst Medical Director or peer reviewer to ensure consistency with clinical standards and policy requirements.

Exclusions

TMS is not covered for the following conditions or clinical circumstances:

• Obsessive-Compulsive Disorder (OCD).
• Acute suicidality.
• Psychotic depression.
• Primary neurological disorders.
• Any use as a first-line treatment for depression.

Billing Guidance

Effective November 1, 2025, the following CPT codes apply to TMS treatment:

Important: CPT codes 90867, 90868, and 90869 may not be billed on the same date of service.

For members enrolled in Healthfirst Medicaid, MAP, or HARP, providers should refer to Healthfirst’s reimbursement policies and billing guidelines for documentation requirements and implementation details.

Provider Action Required

• Review and apply the updated coverage criteria and CPT coding guidance for TMS.
• Confirm member eligibility, accurate diagnosis, and provider qualifications before submitting claims.
• Ensure all supporting documentation and clinical notes are included in the authorization request.

Additional Resources

For more information, please see page 4 of the New York State Medicaid Update, July 2025, Volume 41, Number 7.

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”).
R25-56
November 2025