Transcranial Magnetic Stimulation and Cranial Electrical Stimulation — CPB 0469 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0469 covering transcranial magnetic stimulation (TMS) and cranial electrical stimulation, effective February 27, 2026. Here's what billing teams need to know before submitting claims under CPT 90867, 90868, and 90869.

This update to the Aetna TMS coverage policy tightens the medical necessity criteria and clarifies session limits, supervision requirements, and provider qualifications. If your practice bills TMS for major depressive disorder — or markets MeRT (Magnetic e-Resonance Therapy) — this policy draws clear lines you need to understand before your next claim goes out.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Transcranial Magnetic Stimulation and Cranial Electrical Stimulation
Policy Code	CPB 0469
Change Type	Modified
Effective Date	February 27, 2026
Impact Level	High
Specialties Affected	Psychiatry, Neurology, Mental Health, TMS specialty clinics
Key Action	Audit documentation for all active TMS patients against the updated eight-part medical necessity criteria before billing CPT 90867–90869

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Aetna TMS Coverage Criteria and Medical Necessity Requirements 2026

The Aetna TMS coverage policy under CPB 0469 sets eight conditions that must all be met before TMS is covered. Miss one, and you're looking at a claim denial.

1. FDA-cleared device. The device must carry FDA clearance for the specific indication being treated. Intermittent theta burst stimulation (iTBS) qualifies, but only when used within FDA-labeled parameters. Billing CPT 90868 for off-label device use doesn't fly here.

2. Patient age. The member must be 15 years or older. This is a hard floor — no exceptions documented in the policy.

3. Confirmed diagnosis by a psychiatrist. The diagnosis must be severe major depressive disorder (MDD), single or recurrent episode, without psychosis. A psychiatrist — not a psychologist, not a therapist — must confirm the diagnosis. The severity must be documented with standardized rating scales: BDI, HDRS, or MADRS are specifically named. You need a baseline score before treatment starts, and you need to track changes using the same scale throughout the entire course. If your documentation doesn't include scale scores from day one, the claim is at risk.

4. No contraindications. The policy references a contraindications list. Your treating provider's documentation needs to explicitly address this — a vague note that "TMS is appropriate" won't cut it.

5. Documented medication failures. This is where most denials happen. The member must have failed both of the following during the current depressive episode, within the past five years:

#	Covered Indication Copy
1	Two antidepressants from at least two different classes, each at the maximally tolerated labeled dose, each used for at least eight weeks
2	Augmentation therapy with a primary antidepressant for at least eight weeks, with the augmenting agent at or above the minimal effective therapeutic dose

Both failures must occur during the current depressive episode — defined as the most recent onset of acute symptoms. A prior episode from seven years ago doesn't count. Your clinical notes must document dose levels and duration explicitly.

6. Session limits. Aetna covers a maximum of 30 sessions (five days a week for six weeks), plus six tapering sessions over three weeks — 36 sessions total. Sessions beyond 36 require medical necessity review. Aetna is direct in the policy: there's insufficient evidence that additional sessions help late responders or drive remission in non-responders. Don't assume authorization for more sessions will follow automatically.

7. FDA-approved device for MDD specifically. The device used must carry FDA clearance specifically for major depressive disorder treatment. The policy states treatment should follow manufacturer protocols, with modifications only when backed by published evidence.

8. Psychiatrist or PMHNP oversight. A psychiatrist (MD or DO) or psychiatric-mental health nurse practitioner (PMHNP) must write the order, examine the patient, review the record, and certify the treatment. They must personally oversee initial motor threshold determinations, mapping, treatment parameter definitions, and overall treatment planning. This isn't a "supervising from across the hall" situation — the policy uses the phrase "direct supervision."

For TMS billing to succeed under this coverage policy, your documentation needs to reflect all eight criteria before the first session, not assembled retroactively.

The source policy does not specify prior authorization requirements. Verify prior authorization requirements directly with Aetna before initiating treatment.

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Aetna TMS Exclusions and Non-Covered Indications

Cranial electrical stimulation (CES) is not covered. Full stop. HCPCS E0732 (CES system, any type), A4596 (CES supplies), and related TENS codes (E0720, E0730, A4595, A4557, A4558, A4556) all fall in the non-covered bucket under CPB 0469.

MeRT — Magnetic e-Resonance Therapy — is the other major exclusion, and this is where billing teams at TMS specialty clinics need to pay close attention. The codes used in MeRT protocols (0858T, 0889T, 0890T, 0891T, 0892T, 0997T, 0998T) have no specific Aetna-approved code designation under this policy. Aetna does not cover MeRT. The EEG and ECG codes associated with MeRT workup (CPT 95700–95726, 95812–95824, 93000–93042) are also not covered under this policy for these indications.

If your practice offers MeRT and bills it with TMS-adjacent codes expecting Aetna reimbursement, stop before February 27, 2026. These claims will deny. The policy also states there's no evidence that patients who fail one TMS brand will respond to another brand, to theta burst stimulation, or to deep TMS (dTMS) — which undercuts a common rationale for switching devices and billing for a new course of treatment.

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Coverage Indications at a Glance

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Aetna TMS Billing Guidelines and Action Items 2026

1. Audit your active TMS patient files against the updated eight-part criteria before February 27, 2026.
Pull every Aetna member currently in a TMS course. Verify that baseline rating scale scores (BDI, HDRS, or MADRS) are in the chart, that two antidepressant failures with dose and duration are documented, and that augmentation therapy is noted with the same specificity.

2. Update your charge capture to flag MeRT-related codes.
If your practice uses CPT 0858T, 0889T, 0890T, 0891T, or 0892T for Aetna members, those claims will deny under CPB 0469. Build a billing rule or scrubber alert that stops these codes from going out to Aetna.

3. Verify prior authorization requirements directly with Aetna before treatment begins.
The source policy does not specify prior authorization requirements. Contact Aetna directly to confirm what's required before session one. Don't start a course and sort out authorization later — the session limit is 36, and mid-course surprises are expensive.

4. Track session counts against the 36-session cap in real time.
At session 30, flag the account and verify authorization for the remaining six tapering sessions (sessions 31–36). If the treating provider believes the patient needs sessions beyond 36 total, initiate a medical necessity review proactively — don't wait for a denial.

5. Verify psychiatrist or PMHNP direct supervision documentation.
The policy requires that a psychiatrist (MD or DO) or PMHNP perform the initial examination, write the order, and directly supervise motor threshold determinations and treatment planning. If your TMS program uses a different supervision model, that's a compliance issue. Talk to your compliance officer before the effective date if this applies to your practice.

6. Use the same depression rating scale from baseline through the final session.
This is an explicit policy requirement, not a clinical best practice suggestion. Switching scales mid-course — say, from HDRS to PHQ-9 — breaks the documentation chain. Aetna can deny based on inadequate documentation of treatment response.

7. Do not switch TMS device brands and bill a new course expecting coverage.
The policy explicitly states there's no evidence that failing one TMS device predicts response to another brand, to theta burst, or to deep TMS. Aetna will not treat a brand switch as a new medical necessity basis for a second course of treatment.

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CPT, HCPCS, and ICD-10 Codes for TMS Under CPB 0469

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
90867	CPT	Therapeutic repetitive transcranial magnetic stimulation treatment; planning
90868	CPT	Delivery and management, per session
90869	CPT	Subsequent motor threshold re-determination with delivery and management

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
G0295	HCPCS	Electromagnetic therapy, to one or more areas

MeRT-Related Codes — Not Covered

EEG Codes Associated with MeRT — Not Covered Under This Policy

ECG Codes Associated with MeRT — Not Covered Under This Policy

Not Covered HCPCS Codes — CES and Related Supplies

Key ICD-10-CM Codes Referenced in CPB 0469

Code	Description Copy
C71.0	Malignant neoplasm of brain

Note: CPB 0469 references 368 ICD-10-CM codes total. The full code list is available in the policy source document.

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