Empire BCBS and Anthem TMS Coverage in New York

Empire BlueCross BlueShield plans in New York now operate under the Anthem name, and Anthem New York reviews TMS requests using an MCG Care Guideline, "Transcranial Magnetic Stimulation B-801-T" (28th edition, effective September 1, 2024). MCG guidelines are licensed, proprietary documents, and the B-801-T criteria are not published. This page therefore cannot tell you Anthem's age limit, how many medications you must have tried, whether therapy is required, or how it treats OCD, theta burst or accelerated TMS. It can tell you what is public, which rules apply to which Anthem plans, and how to get the criteria in writing.

Any website that lists specific "Anthem TMS criteria" for New York without citing the current guideline is guessing. Confirm the current criteria with your plan before starting treatment.

Empire is now Anthem

Empire's commercial, Medicaid and Medicare Advantage plans moved to the Anthem brand, with most communications under the new name from January 1, 2024. Member ID numbers did not change. New York commercial plans are now marketed as "Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc." If your card still says Empire, the plan is the same; ask for the Anthem New York behavioral health line when you call.

Which rules apply depends on the type of plan

"Anthem" covers several very different products in New York. The rules for TMS depend on which one you have.

If you have Anthem Medicaid, the state criteria in New York Medicaid TMS coverage apply: age 18 or older, two failed antidepressant trials, and severe depression without psychotic features. If you have an Anthem Medicare Advantage plan, Medicare's New York criteria are the floor; they are explained in Medicare coverage for TMS in New York. The gap is on the commercial side.

What is, and is not, public about the commercial criteria

Anthem's New York provider news announced the move to MCG's 28th edition effective September 1, 2024, and named the TMS guideline B-801-T. It published one TMS-specific rule: "Any requests for CPT code 90869 will be referred for peer clinical review." Code 90869 is the session that includes a new motor threshold determination. Re-measuring the threshold mid-course is sometimes clinically necessary, and motor threshold and TMS dosing explains why. Under Anthem, expect that session to get an extra review.

What is not public:

• The medication, psychotherapy, age and severity requirements in B-801-T.
• Whether theta burst, accelerated or deep TMS is covered, and the position on OCD.
• Session limits, maintenance and retreatment rules.
• Whether a newer MCG edition has replaced the 28th edition for TMS reviews since 2024.
• Anthem's prior authorization rule for TMS, which was not verified for this page.

This page does not fill these gaps with figures from other insurers or from other states' Anthem plans. Anthem plans in other states may use different documents, so an out-of-state summary is not a reliable guide for a New York policy.

How to get Anthem's TMS criteria in writing

You have a right to see them. For group coverage regulated by New York, Insurance Law 3221(l)(5)(D) requires insurers to make their mental health medical-necessity criteria available to insureds, prospective insureds and in-network providers on request. Use it:

1. Call the member services or behavioral health number on your card. Say you are requesting the medical necessity criteria for transcranial magnetic stimulation for major depression, CPT 90867 and 90868, and ask which MCG edition is in use.
2. Ask whether TMS requires prior authorization under your specific plan, and whether a separate behavioral health company handles the review.
3. Put the request in writing as well, through the member portal or by letter, and keep a copy with the date.
4. Ask your psychiatrist or the TMS clinic to request the criteria too. The same New York law entitles in-network providers to the criteria on request.

If your employer's plan is self-funded, the state law above may not apply. In that case, ask the plan administrator, usually reached through your employer's benefits office, for the criteria in writing, and ask which rules govern the plan's appeals.

Preparing a request without the criteria

You do not need to wait for the guideline to start organizing your records. Every published commercial policy reviewed for this hub asks for some version of the same core evidence, so a well-documented history is useful under any criteria set. For comparison, Aetna and Cigna both require a confirmed major depression diagnosis without psychosis, a validated rating scale score, and at least two failed antidepressant trials for adults. They differ on psychotherapy, trial length and protocols, as their pages show: Aetna's criteria, Cigna's criteria and UnitedHealthcare and Optum. These are other payers' rules, not Anthem's.

A file that holds up under most reviews includes:

• The diagnosis, its severity, and a recent score on a validated scale such as the PHQ-9, BDI, HAM-D or MADRS.
• Every antidepressant tried in this episode, with dose, dates and why it stopped.
• Any augmentation medication, with the same detail.
• Psychotherapy: the type, how often, for how long, and scores before and after.
• A screen for seizure history, implanted devices and other safety issues.

The prior authorization guide walks through assembling the request.

Questions to ask on the call

• Which guideline and edition will be used to review a TMS request for major depression?
• Can you send me those criteria, or tell me where my provider can see them?
• Is prior authorization required for CPT 90867 and 90868 under my plan, and how many sessions are approved at a time?
• What is my cost share for this service, in network and out of network?
• What is the reference number for this call?

Write the answers down. If a later denial contradicts what you were told, that record helps on appeal.

Timelines and appeals for New York Anthem plans

For state-regulated New York plans, Insurance Law 4903 requires a preauthorization decision "within three business days of receipt of the necessary information." If Anthem denies the request, you have no less than 45 days to file an internal appeal, and the appeal must be decided by a clinical peer reviewer who was not involved in the first decision. Standard appeals are decided within 30 days, expedited ones within two business days of receiving the necessary information.

A denial upheld on internal appeal as "not medically necessary" or "experimental/investigational" can go to New York's external appeal, which you have 4 months to file. Plans may charge $25 per external appeal, capped at $75 a year, refunded if you win and waived for Medicaid enrollees and in hardship. An appeal is also the point at which you can ask for the exact criterion you were judged on. The full process is in how to appeal a TMS denial in New York, and the parity arguments in New York parity law and TMS claims.

Before you start

Do not begin a course on the assumption that Anthem will pay. Get the criteria, get a written prior authorization decision if your plan requires one, and ask the TMS clinic to confirm with Anthem whether it participates in your specific plan's network. The TMS guide covers the other New York insurers and the clinical questions, and the TMS therapy page describes how a psychiatrist decides whether TMS is the right next step.

Insurance paperwork can take weeks; urgent safety cannot wait for it. If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.

Frequently asked questions

Does Empire BlueCross BlueShield cover TMS?

Empire plans now operate as Anthem in New York. Anthem reviews TMS using the MCG guideline B-801-T. The guideline's criteria are proprietary, so ask the plan for them in writing before starting treatment.

Why can't I find Anthem's TMS criteria online?

Anthem New York uses a licensed MCG Care Guideline for TMS rather than publishing its own policy text. New York insurance law requires insurers to make mental health medical-necessity criteria available to members on request.

Does Anthem Medicaid in New York cover TMS?

Medicaid managed care plans in New York have covered TMS for treatment-resistant major depression since November 1, 2025, under the state's criteria: age 18 or older, two failed antidepressant trials, and severe depression without psychotic features.

Did my member ID change when Empire became Anthem?

No. Anthem's provider FAQ on the rebrand states that member ID numbers did not change.

What is CPT 90869 and why does it matter with Anthem?

90869 is the TMS session that includes a new motor threshold determination. Anthem New York has said every request for 90869 will be referred for peer clinical review.

Sources

1. Frequently asked questions: Our upcoming rebrand to Anthem (Provider Bulletin). Empire BlueCross BlueShield / Anthem (NY), 2023. providers.anthem.com
2. MCG Care Guidelines 28th edition (Anthem NY provider news). Anthem Blue Cross and Blue Shield (New York), 2024. providernews.anthem.com
3. NY Insurance Law Sec. 3221 (l)(5) (group mental health coverage). New York State Senate, 2026. nysenate.gov
4. NY Insurance Law Sec. 4903 (Utilization review determinations). New York State Senate, 2026. nysenate.gov
5. NY Insurance Law Sec. 4904 (Appeal of adverse determinations by utilization review agents). New York State Senate, 2026. nysenate.gov
6. File an External Appeal. NY Department of Financial Services, 2026. dfs.ny.gov
7. New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (Medicaid Update, July 2025, Vol. 41 No. 7). NYS Department of Health, 2025. healthweb-back.health.ny.gov
8. 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) fact sheet. Centers for Medicare & Medicaid Services, 2023. cms.gov
9. LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal, CMS Medicare Coverage Database, 2026. cms.gov
10. Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
11. Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
12. Transcranial Magnetic Stimulation for Treating Physical Health Conditions (CPT code descriptors). UnitedHealthcare, 2026. uhcprovider.com

Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.