How to write a Spravato or TMS prior-auth clinical

A Spravato or TMS prior authorization is a medical-necessity letter, not a progress note and not a REMS checklist. Reviewers look for the indication, adequate antidepressant (and often augmentation) trials with dates and doses, current severity on a named scale, why less intensive care is not enough, and that your site can actually deliver the service. Paste-from-last-visit SOAP fails because it never answers the policy questions in order.

Session documentation is separate: Spravato session and TMS session. Do not send those as the auth packet.

Gather the indication and the failed-trial table

State the diagnosis in payer language. TMS for MDD is often LCD-bound to severe episode codes. Spravato’s label is treatment-resistant depression, or MDD with acute suicidal ideation or behavior, with the REMS setting. If you are requesting TMS for OCD, say OCD and the Y-BOCS, not a depression narrative.

Build a table, even in prose:

• Drug, class, max dose reached, start and stop dates, why it failed (no response vs intolerability), and whether it was combined with psychotherapy.

“Failed two antidepressants” without names is a denial. “Sertraline 50 mg for three weeks, stopped for ‘not liking it’” is not an adequate trial. If the trial was inadequate, say you are not counting it, and count the ones that were.

Include augmentation (atypical antipsychotic, lithium, liothyronine) and psychotherapy attendance if the policy asks. Include ECT if they had it: dates, response, why TMS or Spravato now instead of more ECT.

Quantify severity with scales and function

PHQ-9 or HAM-D for depression, Y-BOCS for OCD TMS, C-SSRS if the Spravato request is the SI pathway. Item 9 and actual ideation belong in the letter if suicidality is part of the indication.

Function: work status, last hospitalization, last ED visit, current LOA. A PHQ-9 of 16 with full-time work is a different packet than a PHQ-9 of 16 with two hospitalizations this year. Both can be valid; they are not the same story.

Attach the scale sheet or quote the date and score. “Severe depression” with no number invites a request for more information, which is a silent denial on the calendar.

Address contraindications and the delivery site

TMS: seizure history, metal in the head, active substance use if the LCD cares, pregnancy if relevant, and that mapping will be done on an FDA-cleared device. Name the protocol (left DLPFC 10 Hz, iTBS, deep TMS) and planned session count (often 36).

Spravato: REMS-certified prescriber, certified pharmacy, two-hour observation capability, blood-pressure monitoring, ride-home plan. Comorbid substance use, aneurysm or vascular history, and current MAOI or other dissociative use if it matters. The auth is not the REMS form, but the reviewer wants to know you will not be dosing in an unsupervised office.

Site of care: outpatient clinic, POS you will bill, who observes. If you are asking for maintenance TMS after a good induction, put the induction response numbers in this letter. Reauth is a new clinical, not a “please extend.”

Write a one-page clinical summary

Open with the ask. Then indication. Then the trial table. Then current severity. Then why not continue oral meds alone. Then safety and site. Then the signature and NPI.

Requesting authorization for a 36-session course of left DLPFC rTMS (90867 x1, 90868 subsequent) for recurrent MDD, severe, PHQ-9 21 on 2026-07-10. Adequate trials: venlafaxine 225 mg 16 weeks (partial, residual anhedonia), bupropion XL 450 mg 12 weeks (insomnia, stopped), aripiprazole 5-10 mg 10 weeks (akathisia). Weekly CBT since March. No ECT. No seizure history. Device: [name]. I will map and set motor threshold at session 1.

Keep emojis, adjectives, and “this life-changing therapy” out. The reviewer is matching a checklist.

File the letter in the chart

Save the submitted clinical, the policy version or LCD you used, the authorization number, unit count, and expiration. When session 18 happens, the TMS note should point at that auth. When Spravato induction ends, the maintenance request needs new PHQ-9 numbers, not the intake letter again.

Admin and clinician should both be able to find it. A denial with “additional records requested” often means the letter lived only in the clearinghouse.

Questions people ask

Can I reuse last year’s Spravato letter? Only as a draft. Trials, scores, and suicidality change. Reauth for maintenance is a new medical-necessity story.

Do I include the full medication list since 2014? Include adequate, dated trials. A 12-year dump buries the two trials the LCD actually requires.