It’s a hard enough challenge to deal with mental health, but navigating the insurance coverage for the TMS therapy maze can make it all the more frustrating. Let’s set your mind at ease by exploring the best ways to get your insurance company to offer coverage or what to do if your insurance company denies coverage.
What is TMS Therapy?
Transcranial magnetic stimulation (TMS) is a depression treatment that uses pulses from a magnetic coil to stimulate specific regions of the brain that are responsible for regulating mood and emotion.
TMS is a safe, highly effective, and FDA-cleared treatment option for depression, OCD, and cigarette cessation. Since 2009, over 70% of Neuro Wellness Spa patients have experienced symptom relief with TMS therapy. Although many mental health conditions are chronic, TMS helps patients achieve remission. TMS treatment is a non-invasive procedure done in an outpatient setting that uses magnetic pulses to stimulate parts of the brain that are dulled or inactive due to mental health disorders like depression, anxiety, or PTSD.
Exploring Insurance Coverage for TMS
Most insurance companies cover TMS therapy and offer TMS coverage under certain conditions. How much coverage for TMS your insurance company provides will be dependent on the specific terms of your insurance plan.
- Explanation Of Benefits (EOB): Each insurance company has an Explanation of Benefits Administrator or document that helps lay out treatment coverage policies and percentages a patient pays vs. insurance coverage payments.
- Deductibles and Out-of-Pocket Max (OOP): Most insurance companies have certain deductibles and OOP’s that need to be met by the patient before 100% coverage kicks in. The TMS provider will be able to check those benefits with you and go over what you might owe.
- Medicare: Some medicare plans cover TMS therapy, however not all providers accept Medicare. Call your benefits administrator for more information on coverage and TMS therapy options.
Common Requirements for Insurance Company Coverage of TMS
Health insurance will require treatment like transcranial magnetic stimulation to be “medically necessary.”
Here are the common requirements for insurance coverage to kick in for TMS therapy.
- Minimum of 18 years old: For those under 18, the treatment would be “off-label,” which likely won’t be covered by insurance.
- Must be diagnosed with Major Depressive Disorder by a certified doctor.
- Has failed at least one attempt at psychotherapy (though some providers require more than one attempt).
- Failure of or adverse effects with at least 2-4 medication attempts, including a diagnosis of treatment-resistant depression.
Each insurance company has different requirements. Call Neuro Wellness Spa today to find out if you are eligible for insurance-covered TMS therapy.
TMS is currently FDA-approved for the following conditions:
- Severe Major Depressive Disorder
- Treatment-Resistant Depression
- Obsessive Compulsive Disorder
- Smoking Cessation
- Migraine Headaches
- Anxious Depression
While research is showing positive results of TMS with other mental health conditions, like bipolar disorder, the FDA will need to approve each one at a time based on research. Approval and clearance come from the benefits of the treatments outweighing the risks. Insurance companies require FDA-approved devices, and some of the device manufacturers require certification or training on specific devices before they can be legally offered.
Prior Authorization Requirements
There’s a good chance your insurance company will require prior authorization before you begin TMS therapy. An experienced TMS provider will have a template for a prior authorization letter ready to send to your insurance.
NOTE: DO NOT start scheduling TMS sessions or getting treatment without confirmation of coverage and approval of prior authorization, or else you could pay out of pocket.
Get a copy of all paperwork submitted on your behalf and keep a notebook of dates and times you contacted the insurance company. Meanwhile, discuss treatment options for the short term, as appeals can take several weeks or months.
Medicare does cover TMS treatment sessions under particular conditions. Some providers will require Medicare Advantage plans to be covered. You must also use a provider who accepts Medicare patients and claims.
TMS therapy is also approved for adult patients, but some approvals stop at 70 years old. New research is showing TMS helps with Alzheimer’s and Geriatric Depression. You will need to confirm your healthcare providers will perform magnetic therapy on people 70 years and older.
In some states, Medicaid offers reduced coverage or no coverage at all for transcranial magnetic stimulation, so you must read the fine print and talk with your provider before proceeding.
What to Do if You Can’t Get TMS Therapy Covered?
There will be instances when an insurance company denies coverage for TMS therapy. Do not give up.
You have a right to appeal the decision as long as the insurance plan isn’t grandfathered before the American Care Act (ACA) was enacted in 2010. Work with your medical provider to give clear reasons and backup documentation for the appeal process.
Insurance plans review coverage each year, and new treatment options are considered to be added to coverage with each new benefit cycle. Ask your provider what it takes for a new procedure to be added to the plan. Insurance providers want to hear from patients to help offer better plans in the future.
Medical financing programs are available from many providers who realize the significant improvement TMS therapy can provide. You can get affordable payments with low or no interest based on your credit score. There are various medical financing programs out there, so research before you apply. Find the best deal, so you don’t risk lowering your credit score by repeated applications on your file.
Can I Pay for TMS Therapy Out of Pocket?
You can, but it should be only as a last resort and only if you have the means to do so. Treatments can cost thousands of dollars, and it’s not a reality for many Americans to fork over that kind of cash – especially since treating depression is challenging, and there isn’t a one-size-fits-all option.
Even if you want to do TMS therapy and it’s not covered, started by doing talk therapy to see if that can help buy you some time until you meet more requirements to get insurance coverage. Explore the different antidepressant medications with your doctor to find one that you can tolerate but also doesn’t have individual negative side effects.
Is TMS Worth It?
Each person will have different results, but most studies have a 60%-80% success rate with short-term or long-term reduction of symptoms. Some people achieve full remission. There are pros and cons of TMS therapy, like any medication, but in most cases, for patients struggling with treatment-resistant depression, TMS is well worth it.
What’s most critical is that you work with our intake team to make sure the medical billing and coding are correct. Between Repetitive Transcranial Magnetic Stimulation (rTMS), Deep TMS (dTMS), and Theta-burst Stimulation (TBS), we can make sure the correct codes are relayed to the insurance companies that match the treatment you’ll be receiving.
Begin Treatment Today
At the Neuro Wellness Spa, we accept the following insurance companies:
- Blue Shield of California
The Neuro Wellness Spa team is dedicated to starting treatment for you as soon as possible, even if there are steps to take before we can explore TMS therapy. We offer treatment recommendations for immediate relief and to achieve long-term goals.