Taking Notes about insurance coverage for TMS Therapy

The Ultimate Guide to Insurance Coverage for TMS Therapy

by Brittany | Mar 17, 2023 | Blog

TMS Therapy, or transcranial magnetic stimulation, is a non-invasive, alternative treatment for depression. TMS therapy uses magnetic pulses to stimulate underactive areas within the brain. TMS Therapy is often confused with electroconvulsive therapy (ECT), a more invasive and intensive procedure involving electric currents to stimulate the brain. Unlike ECT, TMS Therapy does not require sedation, and there is no risk of serious side effects.

TMS Therapy is FDA-approved for treating Major Depressive Disorder (MDD) and Treatment-Resistant Depression (TRD). Offering many people relief from otherwise debilitating illnesses. In addition to treating depression, TMS Therapy has been considered an effective treatment for smoking cessation, anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder. Within the mental health community, TMS Therapy has paved the way as a non-invasive, non-pharmacological, and highly effective treatment; however, navigating insurance and the cost of treatment can be an obstacle.

In this blog post, we want to help you understand the process and changes that impact access to treatment. We will review insurance criteria. factors that affect coverage and give tips for navigating insurance coverage and cost.

Is TMS covered by insurance?

Yes, most insurances cover TMS Therapy for Major Depressive Disorder (MDD) and Treatment Resistant Depression (TRD). It’s important to note that insurance coverage for TMS Therapy can vary widely depending on the insurance plan and provider.

There are several factors we need to consider to determine whether a treatment will be covered by your insurance carrier. These factors include:

✓ The treatment must fall within the covered treatments of the insurance plan.

✓ The treatment provider must be in-network.

✓ The treatment must be deemed medically necessary.

Insurance coverage for TMS Therapy is still evolving. As time goes by, insurance coverage for TMS Therapy is still evolving. For instance, United Healthcare’s policy for TMS Therapy recently changed significantly. Previously, patients had to have a history of four medication failures in two different classes and prior talk therapy to qualify for coverage. However, as of October 2022, United Healthcare now only requires a history of two medications from two different classes alongside a depression diagnostic score (HAM-D).

If you’re considering TMS Therapy, we recommend contacting your insurance carrier to see if your provider of choice is in-network. Request a list of in-network providers from your insurance carrier through member services or look for a “Find a Provider” tool on the carrier’s online portal.

TMS Consultation

The first step in your TMS Therapy treatment journey is consultation. This is an opportunity for patients to ask questions about the treatment and their insurance coverage.

During the TMS consultation, a TMS Coordinator will gather information to perform an insurance benefits investigation. This process involves directly contacting the insurance carrier to review mental health benefits and projected out-of-pocket costs.

Most insurance plans require the submission of prior authorization to receive coverage for TMS treatment. Prior authorization is a detailed report that supports the treatment as medically necessary. In some cases, gathering the documentation for prior authorization can be challenging. This usually involves retrieving records from past providers outlining medication and treatment history. Our team of experts will work with you to understand your coverage options and help obtain the necessary treatment authorization.

What is medical necessity?

For insurance companies to authorize coverage for TMS Therapy, they require proof of medical necessity. Medical necessity means that a specific treatment is clinically necessary based on the patient’s diagnosis and symptoms.

In addition to a diagnosis, the medical necessity for TMS Therapy can be illustrated by a history of unsuccessful treatment. This includes medication history, therapy, in-patient or outpatient treatment, and hospitalizations. Your provider will review your medical history and assess your symptoms to determine if TMS Therapy is medically necessary. This documentation is submitted in a format dictated by the criteria outlined by the insurance carrier, also known as prior authorization.

What are the costs of TMS Therapy?

Determining the cost of TMS Therapy can be tricky and requires a case-by-case review due to the wide variation in insurance plan terms and coverage. Even after receiving insurance approval, patients should expect to pay a copay and/or deductible, which can vary depending on the specific insurance plan. In some cases, insurance may cover the full cost, or a percentage of the cost, of the treatment. For those who need additional financial assistance, payment plans, healthcare financing or medical credit cards from companies like CareCredit may be an option.

Tips for Navigating Insurance Coverage for TMS Therapy

While it can take effort to get insurance authorization, many people successfully navigate the process of getting into treatment with the support of their care team. Here are some tips for navigating insurance coverage for TMS therapy.

Understand your insurance coverage: Review your insurance policy to see if it covers the treatment. Contact your insurance provider to understand your benefits if you are unsure about your coverage.

Work with your BestMind Coordinator: They are experienced with insurance authorization and can help guide you through the authorization process and ensure all necessary information is submitted for the TMS authorization.

Provide medical records: Insurance companies may require documentation of previous treatments and their results before authorizing TMS therapy. To support your coordinator in obtaining the necessary records to support the authorization request, provide them with your medical records from past providers. These records should include your medication history (dose, date rage and reason for discontinuation), therapy history, and any other relevant historical treatments for depression.

Be persistent: TMS authorization can be slow and even frustrating. Be persistent in following up with your insurance company to ensure your TMS authorization request is being reviewed. Stay in communication with your TMS coordinator; they can keep you informed on any changes.

Appeal denials: If your insurance company denies authorization for TMS therapy, you can appeal the decision, work with your TMS provider to gather additional documentation and subfile an appeal. This happens, and it’s best to be prepared for a delay. (Don’t get discouraged.)

Remember that navigating insurance coverage for TMS therapy can be complex, but it is possible with persistence and the help of the BestMind clinical team.