Repetitive Transcranial Magnetic Stimulation (Rtms) Request Form - Bluecross Blueshield Of Texas
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1Transcranial Magnetic Stimulation
rTMS REQUEST FORM
Provider must call BCBSTX at 800-528-7264 to verify benefits.
After completing the form, fax it to BCBSTX at 877-361-7646.
Request Submission Date:_______________________________
Check One:
c Initial Request
c Follow Up Request
Patient Name___________________________________________________
Date of Birth______/_______/_________
Subscriber Name________________________________________________
Subscriber ID #______________________ Group #___________________
Treating Provider/MD Name ____________________________________
Professional Licensure _______________________________________
Address_______________________________________________________
City___________________________State________ Zip_______________
Contact Name________________________ Phone #____________________
NPI#__________________________Tax ID #_________________________
Requested Service Dates _____/______/________ to _____/______/________
CPT Code(s) – # of Sessions: 90867 –____________ ; 90868 – _____________
Clinical Information:
Current Depressive Episode Start Date: _____/______/___________
1. Current Diagnosis (Requiring rTMS Treatment): _____________________________________________Specifier__________________________________
2. Trials of Failed Antidepressants (minimum of four) with its Classification (i.e. SSRI, SNRI, TCA, MAOI, Other):
Antidepressant: ___________________________________________ Class: _________________ Med Trial Dates ___/___/___ to ___/___/___
Antidepressant: ___________________________________________ Class: _________________ Med Trial Dates ___/___/___ to ___/___/___
Antidepressant: ___________________________________________ Class: _________________ Med Trial Dates ___/___/___ to ___/___/___
Antidepressant: ___________________________________________ Class: _________________ Med Trial Dates ___/___/___ to ___/___/___
Antidepressant: ___________________________________________ Class: _________________ Med Trial Dates ___/___/___ to ___/___/___
Antidepressant: ___________________________________________ Class: _________________ Med Trial Dates ___/___/___ to ___/___/___
3. Currently in Cognitive Behavioral Therapy or has had CBT Treatment (Please answer Yes or No)
Provider Name______________________________ Prof Licensure__________________ Started ____/_____/___________
c Yes, Currently
c Yes, In Past
Provider Name______________________________ Prof Licensure__________________ Dates ___/___/___ to ___/___/___
c No, Reasons why CBT cannot be done: _______________________________________________________________________________
_______________________________________________________________________________
4. National Standardized Rating Scales being administered weekly during treatment?
Rating Scale being Utilized: ___________________________________________________________________________
c Yes
Reason? ______________________________________________________________________________________
c No
5. Are any of the following conditions present?
c Seizure disorder or any history of seizure disorder (except those induced by ECT or isolated febrile seizures in infancy without subsequent treatment or recurrence)
c Presence of acute or chronic psychotic symptoms or disorders (e.g., schizophrenia, schizophreniform or schizoaffective disorder) in the current depressive episode
c Neurological conditions that include epilepsy history, cerebrovascular disease, dementia, increased intracranial pressure, repetitive or severe head trauma, or primary or secondary
tumors in the central nervous system
c Excessive use of alcohol or illicit substances within the last 30 days
c No response by patient to a prior course of rTMS treatments (defined as not achieving at least a 50% reduction in severity of scores for depression in a standardized rating scale
(i.e. PHQ-9) by the end of acute phase treatment
c The patient has received a separate acute phase rTMS treatment in the past 6 months
c None of the above are present.
Signature ___________________________________________________________ Date _________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
728023.0915
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