TMS THERAPY
FDA-cleared, non-medication depression treatment
TMS FAQs: Does Insurance Cover TMS Therapy?
Erika Krull, MSEd, LMHP
Medically reviewed on 12/2/2020 by
Dr. Geoffrey Grammer
Chief Medical Officer
Insurance coverage can be confusing, especially with a treatment that's new to you. Here, you'll find answers to some pressing questions about insurance and Transcranial Magnetic Stimulation (TMS) therapy. You'll understand more about the requirements, how to improve the chances of getting TMS therapy covered by insurance, and if TMS therapy is covered by Medicare or Medicaid.
Does Insurance Cover TMS Therapy?
The short answer is yes—but there's more to the story.
As a rule, insurance companies won't pay for a service or procedure unless they consider it medically appropriate or necessary. While every insurance company's policies are different, the following general criteria typically dictate whether TMS therapy will be covered:
- You've been diagnosed with moderate-to-severe Major Depressive Disorder (MDD).
- You are not seeking TMS for conditions that are not covered. For example, treatment of bipolar disorder, anxiety, ADHD, tinnitus, migraine headaches, or chronic pain is not covered.
- You have documentation that at least two (sometimes four) depression medications have not been helpful.
- You made an adequate attempt at talk therapy known to be effective for treating depression but showed little improvement.
Some insurance companies have a longer list of requirements for coverage than others.
Circumstances That May Disqualify You from Coverage
Insurance companies may not cover TMS therapy in all situations, even if your treatment is medically necessary. Your insurance may not cover TMS treatment if the following apply to you:
- You are currently pregnant or nursing.
- You're at acute risk for suicide.
- You demonstrate ongoing substance abuse (alcohol, prescription drugs, or illicit drugs).
- You've been diagnosed with neurological conditions such as epilepsy, seizure disorders, or dementia.
- You have magnetic-sensitive medical devices or objects such as cochlear implants, bullet fragments, or stents near the areas where the TMS devices would be placed.
Is TMS Therapy Covered by Medicare or Medicaid?
The short answer is yes, but coverage may vary depending on your specific Medicare or Medicaid plan. 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. Medicare and Medicaid are accepted at various Greenbrook center locations; call 855-940-4867 to find a nearby location or enter your zip code in our center locator.
Here are the key requirements for basic Medicare coverage of TMS therapy:
- You've been diagnosed with severe MDD by a Medicare-approved physician.
- The treatment provider must be able to accept Medicare's approved reimbursement as full payment for the service.
- You've previously attempted to treat depression with medication without success, or medication is not recommended for health reasons.
Insurance Coverage for TMS: How to Improve Your Chances
Ultimately, insurance companies have the final say on how much they'll pay for medical services. Although you can't control their decisions, you can often improve your odds of getting coverage. With TMS therapy, the key to coverage is meeting two overarching requirements: your diagnosis must meet their specific standards, and you need a solid history of trying the most common depression treatments. Here are some tips and recommendations to help your TMS therapy qualify for insurance coverage:
1. Show a Well-Documented History of Previous Treatment Attempts.
Having accurate treatment records is essential. It's especially important if you've stopped taking a medication due to side effects or other complications. Make sure to report your progress (or lack thereof) honestly with your doctors so that they can understand these issues accurately and document your experience clearly.
2. Follow Each Treatment as Completely as Possible.
Many insurance requirements look for eight consistent weeks of talk therapy or medication use. It's normal to forget to take medication once in a while, and sometimes it's hard to make every appointment. And if you aren't feeling better, it's easy to give up before your doctor tries something else. Talk with your provider about adverse effects and give it your best shot, even with the ups and downs. When trying other treatments before considering TMS, follow your treatment recommendations as best you can.
3. Recognize Other Conditions or Circumstances That May Limit Your Coverage.
Each insurance company has its own list of reasons why they might not cover a treatment or procedure. Some may be short-term situations that can change; others may be a medical diagnosis that you have no control over. We'll work with you to help you understand your company's requirements.
Insurance and TMS: Planning and Peace of Mind
So, does insurance cover TMS therapy? Yes, but there are exceptions—and the details can make a big difference. One of the reasons Greenbrook offers free consultations is so you can discuss your insurance considerations without obligation. When you go through TMS therapy at Greenbrook, the Care Team will help you understand the process, answer any questions you may have, and work with you every step of the way.
With some research and planning, you can get started with TMS treatment and continue your journey to achieve peace of mind.
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