Is TMS Covered by Medicare?

TMS is one of the most effective treatments for depression, especially for patients who have failed to achieve a positive response from antidepressants and therapy.

Depression is one of the most prevalent mental health disorders worldwide, affecting over 280 million people around the world. Characterized as a mood disorder, depression is often experienced as having persistent feelings of sadness and disinterest in daily activities. When left untreated, depression can cause severe health complications that have long-lasting impacts on both your physical and emotional health. Depression can interfere with or limit one’s ability to carry out major life activities, and it can impact your relationships and work life, causing the person affected to suffer greatly.

Antidepressant medications and psychotherapy are the first option of treatment prescribed in patients suffering from depression. However, these treatments do not work for all patients. Transcranial magnetic stimulation, or TMS, is a treatment option for depression that is becoming more common amongst patients due to the successful outcomes of the treatment over the past decade. This treatment therapy is non-invasive and shows promising potential for many patients, and is now covered by Medicare plans.

Insurance coverage can be confusing, especially with a treatment that is newer like TMS therapy. After reading this article, you’ll understand how to improve the chances of getting TMS therapy covered by insurance and if it is covered by Medicare or Medicaid.

Patients who have failed to achieve an adequate response from antidepressant medications or who are unable to tolerate medications, should consider TMS therapy. Image courtesy of www.riverviewpsychiatric.com.

What is TMS?

Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain in order to improve symptoms of mental disorders like depression.

TMS therapy includes the use of a device to generate magnetic fields that can stimulate the brain, which alters the brain’s chemistry and reduces symptoms of depression.

Because this treatment for depression often involves delivering repetitive magnetic pulses, it's called repetitive TMS (rTMS). In 2008, rTMS was approved for use by the FDA (Food and Drug Administration) as a treatment for major depression. Repetitive transcranial magnetic stimulation (rTMS) uses an electromagnetic coil to activate the brain by placing it against the scalp.

The electromagnet painlessly delivers a magnetic pulse that stimulates nerve cells in the regions of the brain that show decreased activity in depression, easing symptoms and improving overall mood.

Prior to scheduling you for treatment, you must first be evaluated by a TMS psychiatrist to determine if TMS would be safe and the best option for you.

TMS Therapy is a great option for patients with Major Depressive Disorder who have failed to benefit from initial treatment of their depression. Image courtesy of www.embracinglifetoday.com.

Does Medicare Cover TMS Treatments?

Yes! Medicare has started offering coverage for TMS treatments due to the treatment’s success rates with patients. In order to be eligible for coverage, the patient must be diagnosed with severe major depressive disorder by a Medicare-approved physician. In most cases, the patient must also have already attempted to treat symptoms by using medications. Coverage may vary depending on your specific Medicare or Medicaid plan.

Here are the main requirements for Medicare coverage of TMS Therapy:

You have been diagnosed with moderate-to-severe Major Depressive Disorder.
You've previously attempted to treat depression with medication and have had little to no success in treating symptoms. Or if you cannot take medication due to health reasons.
The treatment provider must be able to accept Medicare’s approved reimbursement as full payment for the procedure or service.

If all requirements are met, Medicare may pay for 80% of the treatment cost. You'll still be responsible for the annual deductible before any coverage kicks in, and you may also need to cover the remaining 20% of the cost, as well as your monthly premiums. Make sure to choose a Medicare-approved physician that provides TMS therapy in order to receive coverage for this treatment.

I don't have Medicare, will my insurance cover TMS Treatments?

The short answer is yes, although as a rule, insurance companies will not pay for a service or procedure unless they consider it medically necessary or appropriate. Thankfully, insurance companies are beginning to understand the cost-effectiveness of TMS treatment when looking at the big picture of a patient who continues to trial, unsuccessfully, one antidepressant medication after another. Then, in most cases, while the depression symptoms worsen, other complications start to arise. Such as acquiring a substance use disorder which can compound the medical costs of untreated Major Depressive Disorder. Now insurance providers are offering coverage for TMS therapy when certain criteria are met, considering the collateral effects of untreated Major Depressive Disorder.

Every insurance company’s policies are different, but the general criteria below typically dictate whether or not TMS therapy will be covered:

You have been diagnosed with moderate-to-severe Major Depressive Disorder.
You have made an attempt at talk therapy in order to treat your depression, but talk therapy has shown little to no improvement.
You provide documentation that at least two depression medications you have tried have not helped with symptoms.
You are not seeking TMS for conditions that are not covered including treatment of anxiety, ADHD, migraine heachaches, bipolar disorder, tinnitus, or chronic pain is not covered.

Of course, each insurance company's requirements vary and some insurance companies may have a longer list of requirements in order to receive coverage compared to others.

Insurance companies that cover TMS therapy

TMS therapy is covered by most insurance companies. Many insurance companies pay for TMS therapy for depression because it’s effective and FDA-approved for the treatment of major depressive disorder. Image courtesy of bostonscientific.com.

Over 300 million Americans have insurance policies that cover TMS treatment. If you meet the requirements for TMS therapy, most major insurance companies will typically cover the treatment, including but not limited to:

Aetna
Ambetter
Anthem
Beech Street
Blue Cross Blue Shield
Cigna
Compsych
First Choice Health
Humana
Kaiser
New Directions
Optum
Prominence Healthcare
Teachers Health Trust
Tricare
United Healthcare
UPMC Healthcare
ValueOptions
Wellcare

In order to try and improve your chances of your insurance policy covering TMS therapy, it is extremely important to maintain accurate treatment records and honestly report your progress or lack of progress with your doctors.

What if my insurance provider doesn’t cover TMS?

If your insurance company denies coverage for TMS therapy, or if you are interested in trying TMS for a condition other than Major Depressive Disorder (MDD), there are various medical financing programs available to make the treatment accessible to those. Some providers even offer sliding-scale pay options based on your income levels.

Medical insurance companies usually only cover medically necessary services or procedures. Fortunately for those with treatment resistant depression, Transcranial Magnetic Stimulation (TMS) therapy is now considered medically necessary and is therefore covered by many insurance company’s policies. This treatment therapy is non-invasive and shows promising potential for many patients, due to the successful outcomes of the treatment over the past decade. However, there are some limits to coverage that can vary among insurance providers, so make sure to check with your benefits administrator before scheduling TMS sessions.

Back to Blog