Cigna TMS Prior Authorization Removal in 2026: What Billing Teams Need to Change Now

On March 6, 2026, Evernorth's contracted-provider FAQ announced that prior authorization would be removed for TMS when rendered by Evernorth contracted providers whose patients have coverage under Evernorth and Cigna Healthcare plans. Below we break down the operational shift for clinics impacted by the Cigna TMS policy change.

What did not change is the coverage standard behind the claim. Evernorth's current coverage policy EN0383 still defines who qualifies for TMS, when repeat courses are covered, and which uses remain non-covered. In other words, the prior-auth step changed, but the medical-necessity framework did not.

That matters because a denied TMS course can still put meaningful revenue at risk. A published consensus paper in Brain Stimulation noted that an acute U.S. rTMS course of 20 to 30 sessions may range from $6,000 to $12,000, although actual reimbursement varies by payer, contract, and protocol.

From our work in this area, that is the part clinics are most likely to misread. The removal of the prior auth requirement reduces one administrative step. It does not mean the chart can be lighter, the intake process can be looser, or the claim no longer has to stand up to medical-necessity review. Operationally, the main shift is that the missing requirement is less likely to be surfaced before treatment starts and more likely to surface during claim review, potentially resulting in revenue at risk.

This is what changed, what did not, and what your billing team should adjust now.

What Actually Changed on March 6, 2026

According to Evernorth's March 2026 FAQ for contracted providers and its companion TMS request form:

• Prior authorization is no longer required effective March 6, 2026.
• The change applies to Evernorth contracted providers whose patients have coverage under Evernorth and Cigna Healthcare plans.
• Out-of-network providers remain subject to medical-necessity review, and the FAQ says some plans may or may not require prior authorization depending on the Summary Plan Description.
• Network exception requests still require separate handling and can still require prior authorization.
• Evernorth tells clinics to keep using the same benefit-verification process they used before rendering services.

For many in-network clinics, that means you no longer need to wait for a TMS authorization number before starting treatment. It does not mean every Cigna-related plan behaves the same way, so eligibility, network status, and plan-specific coverage still need to be verified before session 1.

What Did Not Change

For major depressive disorder, EN0383 says an initial 30 to 36 treatment course is medically necessary when all of the following are met:

• The patient is age 15 or older.
• The diagnosis is moderate-to-severe unipolar major depressive disorder, single or recurrent episode or acute relapse, without psychosis.
• During the current episode, the patient had an adequate trial of evidence-based psychotherapy without significant improvement.
• Validated depression monitoring scales are administered at the beginning and end of the initial and each subsequent course.
• Medication history meets the policy standard:
  • Adults age 18 or older must have failed two or more antidepressant trials from two separate classes.
  • Adolescents age 15 to 17 must have failed two antidepressant trials.

For obsessive-compulsive disorder, EN0383 says deep TMS for OCD is medically necessary only when all of the following are met:

• The patient is age 18 or older.
• The patient has an OCD diagnosis.
• The patient failed two or more psychopharmacologic medication trials for OCD.
• The patient had an adequate trial of evidence-based psychotherapy without significant improvement.
• Y-BOCS is administered at the beginning and end of the initial and each subsequent course.

Repeat courses are also constrained. EN0383 allows repeat TMS for relapse or recurrence only when the prior course produced a documented response and that improvement was maintained for at least two months. The same policy also says maintenance TMS is not medically necessary.

The Billing Workflow Shift

The simplest way to understand the change is this: the front-end authorization checkpoint is gone for many contracted-provider cases, but the payer's coverage rules are still there.

Old workflow:

1. Verify eligibility.
2. Submit the TMS prior-auth request.
3. Get a yes or no before treatment starts.
4. Treat and bill.

New workflow for contracted-provider cases covered by the March 6 Evernorth change:

1. Verify eligibility, network status, and plan-specific TMS coverage.
2. Make sure the chart can substantiate the same clinical facts Evernorth previously requested on its TMS form.
3. Start treatment.
4. Bill the services and be prepared for medical-necessity review at claim adjudication or later record review.

That changes where the risk shows up. Instead of a missing requirement being surfaced before treatment starts, it is more likely to show up when the claim is reviewed.

The Documentation Standard Should Not Drop

A practical rule of thumb is this: if your team used to collect it because Evernorth's request form asked for it, you probably still need it in the chart.

At minimum, your intake and pre-treatment workflow should reliably capture:

• Diagnosis and current episode details.
• The rating scale used and the baseline score.
• Medication history with classes, dates, dose ranges, and response or intolerance.
• Psychotherapy history tied to the current episode.
• Contraindication screening, including seizure history and implanted magnetic-sensitive metal within 30 cm of the coil.
• Prior TMS history and documented response if this is a repeat course.

Even if you are no longer submitting the form for many contracted cases, it is still a useful front-end documentation checklist.

CPT Code Reminders for TMS Billing

EN0383 lists these covered TMS CPT codes:

• 90867: Initial TMS treatment, including cortical mapping, motor threshold determination, delivery, and management
• 90868: Subsequent delivery and management, per session
• 90869: Subsequent motor-threshold redetermination with delivery and management

CMS billing guidance and NCCI policy are aligned on a few operational points that matter here:

• 90867 is the initial code and should be reported once per treatment episode.
• 90867 should not be billed together with 90868 or 90869.

Evernorth's March 2026 FAQ also addresses multiple TMS sessions in a day and tells providers to follow FDA protocols and verify the applicable edit limits. Commercial plans can still layer on their own edits, so payer-specific billing checks still matter even when prior auth is removed.

Immediate Workflow Changes to Make

1. Update your TMS intake checklist. Base it on EN0383 and the March 2026 Evernorth request form, not on an older internal SOP.

2. Separate benefit verification from prior-auth logic. The question is no longer just "Do we need prior auth?" It is "Is this a contracted-provider case under a plan that follows the March 6 rule, and does the patient meet the current policy criteria?"

3. Tighten medication and psychotherapy history capture. "Failed two meds" is not enough. The supporting record should show class, timing, duration, and why the trial failed or could not continue.

4. Track post-March-6 Evernorth/Cigna TMS claims as their own cohort. If denials start clustering around medical necessity or documentation, you want to see that pattern quickly.

5. Train staff on repeat-versus-maintenance language. EN0383 allows repeat courses under specific relapse criteria, but it says maintenance TMS is not medically necessary. Those are not interchangeable terms.

What This May Mean for Other Payers

Do not generalize this change across the rest of your payer book yet. There is broader transparency pressure around prior authorization but it does not affect every commercial payer yet. Under CMS's Interoperability and Prior Authorization final rule, impacted payers including Medicare Advantage organizations, Medicaid and CHIP programs, and Qualified Health Plan issuers on the federally facilitated exchanges must publicly report certain prior-authorization metrics on their websites, with the initial report due by March 31, 2026. That rule does not cover every commercial payer and it is not TMS-specific, but it is part of the broader environment pushing plans to justify prior-authorization programs with data.

Clinics That Also Run SPRAVATO Need a Separate Workflow

If your clinic offers both TMS and SPRAVATO, do not collapse them into one authorization process.

TMS now has a no-prior-auth path for many contracted-provider cases covered by the March 6 Evernorth change. SPRAVATO does not map cleanly to that model. Janssen's current access, coding, and reimbursement guide makes clear that SPRAVATO coverage can involve medical or pharmacy benefits, and prior-authorization requirements are plan dependent. That is why the safest operational assumption is not "SPRAVATO always requires PA," but "SPRAVATO has its own benefit and authorization workflow that must be verified plan by plan."

That complexity also shows up in published access data. In a U.S. claims analysis of patients whose first esketamine claim was a pharmacy claim, only 34.6% were approved, 46.3% were rejected, and 19.1% were abandoned. Among the listed rejection reasons was "prior authorization required." That is not a pure medical-benefit prior-auth statistic, but it is a useful reminder that SPRAVATO access remains its own workflow problem.

If you want a payer-specific starting point, Janssen's SPRAVATO payer coverage lookup tool is a better reference than trying to reuse a TMS workflow.

FAQ

Does Cigna's change apply to every TMS patient?

No. Evernorth's March 2026 FAQ says the change applies to Evernorth contracted providers whose patients have coverage under Evernorth and Cigna Healthcare plans. Out-of-network cases still need separate review, and some plans may or may not require prior authorization depending on the Summary Plan Description, so clinics should verify the patient's specific plan before treatment starts.

Can TMS claims still be denied without prior authorization?

Yes. The prior-auth step changed. The coverage policy did not. Claims still need to be supported by the plan's medical-necessity criteria and clean documentation.

Did the clinical criteria change too?

Not based on the current policy documents. EN0383 still sets detailed criteria for MDD, OCD, repeat courses, and non-covered uses.

Does this change make OCD TMS easier to start for adolescents?

No. The current Evernorth policy distinguishes between MDD and OCD. MDD can be covered from age 15. OCD coverage in EN0383 is for deep TMS in adults age 18 and older.

What should billing teams use as their source documents now?

Use the March 2026 Evernorth FAQ and TMS request form for the operational workflow, and EN0383 for the actual coverage criteria. The FAQ and form reflect the prior-auth change. The policy still governs medical necessity.

Does this affect SPRAVATO prior authorization requirements?

Not directly. SPRAVATO remains a separate reimbursement workflow that can run through medical or pharmacy benefits depending on the payer and plan. Prior-authorization requirements should be verified plan by plan, not inferred from the new TMS rule.

What CPT codes apply to standard TMS billing?

90867, 90868, and 90869. Evernorth lists all three in EN0383. CMS guidance says 90867 is reported once per treatment episode and not together with 90868 or 90869.

Bottom Line

Cigna/Evernorth removed one gate, not the underlying coverage standard. For contracted providers covered by the March 6 Evernorth policy change, the TMS prior-auth step is gone as of March 6, 2026. The operational consequence is that the front end of your workflow has to get more disciplined, not less, because the chart has to stand on its own without a pre-treatment payer decision.

If your team treats this as a documentation-lightening event, it is probably solving the wrong problem. The better response is to rebuild intake, coverage verification, and repeat-course review around the policy that still exists.