Is TMS Covered By Insurance?
Yes, TMS is generally covered by many health insurance plans for people diagnosed with major depressive disorder or treatment-resistant depression who have not experienced adequate relief from antidepressant medications. However, coverage requirements vary depending on your insurance provider and individual plan.
Many insurance companies require patients to have tried at least two different antidepressant medications without achieving sufficient improvement before approving Transcranial Magnetic Stimulation (TMS) therapy. Some insurance plans may require patients to have tried additional medications or treatments. Certain insurers may also require a documented trial of talk therapy, such as psychotherapy or counseling, before TMS treatment can be approved.
Because every insurance plan has different criteria, meeting the general requirements does not automatically guarantee coverage. Your diagnosis, treatment history, medications you have previously tried, and response to those treatments may all be considered when your insurance company determines whether TMS is medically necessary.
What Are The Insurance Eligibility Criteria For TMS Coverage?
While requirements vary, insurance companies commonly look for documentation showing that you have:
A diagnosis of major depressive disorder or another qualifying condition (like OCD or anxious depression)
Tried at least two antidepressant medications without adequate relief
Experienced an inadequate response, intolerance, or adverse effects from previous medications
Participated in psychotherapy or talk therapy, when required by your insurance plan
Been evaluated by a qualified healthcare provider who determines that TMS is medically appropriate
Some insurance providers may have additional requirements, such as specific medication dosages, treatment durations, or a greater number of failed medication trials.
Why Might Insurance Deny Coverage For TMS?
Meeting the general requirements for TMS does not guarantee insurance coverage. Insurance companies have their own eligibility and medical-necessity criteria, and certain circumstances may prevent a patient from qualifying for covered TMS treatment.
Your insurance may deny coverage for TMS if you:
Lack sufficient documentation of your treatment history.
Have a diagnosis other than Major Depressive Disorder.
Are at heightened risk for seizures or epilepsy.
Have a history of psychosis or are diagnosed with Schizophrenia.
Are under 18 or over 65 years of age.
Have a history of substance abuse.
Have metal implants or pacemakers.
Because requirements vary significantly between insurance companies and individual plans, there is no single list of circumstances that automatically disqualifies everyone from insurance-covered TMS. Clear TMS+ can help verify your benefits and determine what requirements your insurance plan may have before you begin treatment.
Aetna
BlueShield
BlueCross
Magellan Health
Cigna
Which Insurance Companies Cover TMS?
Medicare / Medicaid
Optum
Health Net
Tricare
MHN Health
United Healthcare
If you don’t see your insurance provider listed here, that doesn’t mean you don’t have coverage. Contact us or call your insurance provider to see if TMS is available with your insurance plan.
Does Medicare / Medicaid Cover TMS Therapy?
Yes, Medicare and Medicaid usually cover TMS therapy for qualifying patients.
What To Do If Insurance Denies Coverage For TMS?
Depending on the reason for the denial of coverage, you may still be able to get it covered after meeting specific requirements, such as trying another antidepressant or attending talk therapy. If your coverage is denied, talk to your insurance provider about the reasons for the denial.
How Much Does TMS Cost Without Insurance?
The cost for treatment without coverage will depend on the number of sessions and the length of your treatment. If your coverage is denied, reach out to us and we can discuss other payment options.
How Much Does TMS Cost With Insurance?
The cost of TMS therapy with insurance varies depending on your health insurance plan, deductible, copay or coinsurance, out-of-pocket maximum, and whether or not our clinic is considered in-network. Even when TMS is covered by insurance, you may still be responsible for a portion of the treatment costs.
For many patients, insurance coverage can significantly reduce the cost of TMS compared with paying for treatment out of pocket. Some patients may have a relatively small copay for each treatment session, while others may need to meet a deductible before their insurance begins paying for covered services. Your total cost will depend on the specific benefits included in your plan.
A typical course of TMS for depression may involve approximately 30 to 36 treatment sessions over several weeks. Because of the number of appointments involved, even a relatively small copay or coinsurance amount per session can add up over the course of treatment.
Before beginning TMS treatment, it is important to verify your benefits and understand your potential financial responsibility. Clear TMS+ can help you determine whether your insurance plan covers TMS and what requirements may need to be met before treatment is authorized. Because insurance benefits vary by individual plan, we recommend confirming your specific coverage before beginning treatment.
Reach out today to start your journey toward mental wellness.
References:
Lam, R. W., Chan, P., Wilkins-Ho, M., & Yatham, L. N. (2008). Repetitive transcranial magnetic stimulation for treatment-resistant depression: A systematic review and metaanalysis. Canadian Journal of Psychiatry, 53(9), 621-631. https://doi.org/10.1177/070674370805300909
