Transcranial magnetic stimulation (TMS) is a revolutionary therapy that’s changing the way we treat major depressive disorder and other mental health conditions. Thankfully, more insurance providers are recognizing the value of this innovative treatment and expanding their coverage to make it more accessible.
If you’re considering TMS and have Humana insurance, this article will help you understand what’s covered and the steps needed for approval.
What is TMS therapy?
Transcranial magnetic stimulation (TMS) therapy is a safe, non-invasive treatment that uses gentle magnetic pulses to stimulate parts of the brain involved in mood regulation. It’s mostly used to treat major depressive disorder (MDD), particularly for those who haven’t found sufficient relief through traditional treatments like antidepressant medications or talk therapy (known as treatment-resistant depression).
There are two main types of TMS therapy:
- Repetitive TMS (rTMS): rTMS is the most widely-used form of TMS therapy. It delivers repeated magnetic pulses to the dorsolateral prefrontal cortex (DLPFC), a region of the brain that’s often underactive in people with depression. rTMS involves placing a figure-8 shaped magnetic coil against the scalp to stimulate neurons and help rebalance brain activity.
- Deep TMS (dTMS): dTMS uses an H-coil, housed inside a helmet, to reach deeper brain structures. It stimulates a broader area of the brain and may be used for certain treatment-resistant cases or other mental health conditions such as obsessive-compulsive disorder (OCD).
One of the main benefits of TMS therapy is that it doesn’t require medication, anesthesia, or sedation. Patients remain awake and alert during treatment and can return to normal daily activities immediately after a session. TMS sessions usually last between 20 to 40 minutes and a course of treatment involves five sessions per week administered over four to six weeks, depending on a person’s needs.
Another benefit of TMS therapy is that it’s generally well tolerated with minimal side effects. The side effects that do occur, like headaches, scalp discomfort, or lightheadedness, are mild and short-lived, typically resolving on their own. More serious side effects, like seizures, are extremely rare and occur in less than 1% of patients.
Note that TMS is different to electroconvulsive therapy (ECT). While both are brain stimulation treatments used to treat depression, TMS does not induce seizures, does not require hospitalization, and has no recovery time.
Learn More: TMS vs. ECT: Which is better?
What is TMS therapy FDA-approved to treat?
TMS therapy has been studied extensively and is currently approved by the U.S. Food and Drug Administration to treat several mental health and neurological conditions, including:
- Major depressive disorder (MDD): TMS is most commonly used to treat adults and adolescents above 15 with treatment-resistant depression, where two other antidepressant medications have been tried and failed to provide sufficient relief.
- Obsessive-compulsive disorder (OCD): Deep TMS is FDA-approved for people with moderate to severe OCD who haven’t found relief through traditional treatments like therapy or medication. dTMS targets deeper regions of the brain linked to obsessive and compulsive thought patterns.
- Smoking cessation: TMS is also approved as a tool to help reduce nicotine cravings and cigarette consumption. Studies have shown that stimulating specific areas of the brain involved in addiction can support efforts to quit smoking.
- Migraine prevention: Certain TMS devices are FDA-approved to treat and prevent migraine headaches, offering a non-invasive and non-medical option for those who experience frequent or debilitating migraines.
Read More: TMS for Migraine: Benefits, Effectiveness, Precautions
Off-label uses of TMS
While not yet FDA-approved for these conditions, research has found TMS to be effective in treating:
- Generalized anxiety disorder (GAD)
- Post-traumatic stress disorder (PTSD)
- Bipolar disorder
- Chronic pain and fibromyalgia
- Tinnitus
- Autism.
Many providers offer off-label use of TMS in managing these conditions.
See: TMS Treatment for Autism: What is it and Does it Work?
Does Humana cover TMS therapy?
Yes, Humana covers TMS therapy for major depressive disorder (MDD) when it’s considered medically necessary. According to Humana’s coverage guidelines, TMS therapy is only considered medically necessary when all of the following conditions are met:
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- Age: The patient must be 15 years or older
- Diagnosis: There must be a formal diagnosis of major depressive disorder based on DSM-5 diagnostic criteria
- Medication treatment history: One of the following must apply:
- Failure of antidepressant trials:
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- During the current depressive episode, the patient has tried at least four antidepressant medications from at least two different classes and hasn’t experienced a clinically significant response
- At least two of these trials must have involved an adequate course of treatment, defined as standard therapeutic doses administered over at least six weeks
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- Inability to tolerate antidepressants:
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- The patient must be unable to tolerate psychopharmacological agents, as demonstrated by trying four different agents which have caused distinct, intolerable side effects
- Alternatively, the patient is taking necessary medications which may interact negatively with antidepressants, making them unsafe to use.
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- Other treatments considered: Electroconvulsive therapy (ECT) must have been either previously attempted, deemed medically contraindicated, or offered and declined by the patient
- No contraindications: There must be no contraindications to TMS therapy (for example, the presence of metal implants near the head)
- Psychiatrist referral: The patient must submit a referral from a licensed psychiatrist before treatment begins.
Learn More: What to Do When Antidepressants Don’t Work for You (and Why)
Does Humana cover maintenance TMS?
At this time, Humana does not offer coverage for maintenance TMS therapy as it’s not considered medically necessary. The reasoning behind this is that there’s insufficient evidence to support its ongoing use beyond an initial treatment course.
Does Humana cover TMS re-treatment?
Yes, Humana covers TMS re-treatment for those who meet specific clinical criteria. Re-treatment may be approved when there’s evidence that the patient initially responded to TMS therapy but has since experienced a significant return of depressive symptoms.
According to Humana’s coverage guidelines, TMS re-treatment is considered medically necessary when all the following conditions are met:
- Worsened symptoms: There’s documentation showing that current major depressive symptoms have worsened by at least 50% compared to the individual’s prior best response, based on PHQ-9 scores (a standard depression screening tool)
- Prior treatment success: The initial course of TMS therapy must have resulted in a 50% or greater reduction in depression severity from baseline measurements
- No new contraindications: There must be no contraindications to undergoing TMS therapy again.
If you’re considering TMS re-treatment, it’s important to discuss your full medical history with your TMS provider to make sure you’re still eligible under Humana’s guidelines.
What are TMS contraindications according to Humana?
Humana may not approve TMS for individuals with any of the following contraindications:
- Active suicidal ideation
- History of or risk factors for seizures during TMS therapy
- Presence of vagus nerve stimulators, pacemakers, or other implants controlled by physiologic signals
- Conductive, ferromagnetic, or magnetic-sensitive metals implanted in the head or neck within 30 cm of the treatment coil (e.g. aneurysm clips, metal plates, deep brain stimulation devices, or cochlear implants)
- Active or inactive neurostimulator implants
- Active psychosis or catatonia requiring urgent intervention
- History of seizures (except those induced by electroconvulsive therapy)
- Severe substance use disorder at the time of treatment
- Diagnosis of severe dementia
- Diagnosis of severe cardiovascular disease.
Read More: Who Qualifies for TMS Therapy? (TMS Requirements)
Does Humana cover TMS for adolescents?
Yes, Humana now covers TMS therapy for adolescents in response to the FDA’s recent clearance of NeuroStar TMS for adolescents aged 15 to 21 with MDD. In fact, it was the first commercial issuer to update its policy to include this age group.
Under the updated policy:
- Adolescents aged 15 to 17 can now access TMS therapy through Humana coverage
- Treatment requests for individuals in this age group require medical director review to ensure it’s appropriate and medically necessary.
Learn More: Is TMS Appropriate for Treating Adolescents With Depression?
How to get insurance coverage for TMS therapy
If you’re exploring TMS therapy, it can feel overwhelming to navigate insurance coverage and understand your eligibility. The good news is that you don’t have to do it alone – our team is here to help!
Below is an idea of what’s involved in the insurance coverage process for TMS:
1. Start with a formal diagnosis
The first step towards getting TMS coverage is getting a formal diagnosis from a licensed mental health professional.
For Humana, TMS is approved for major depressive disorder (MDD) but other insurance providers might also cover TMS for obsessive-compulsive disorder (OCD). Your diagnosis must be based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and be supported by a clinical evaluation.
If you haven’t received a diagnosis yet, reach out to our team to schedule an initial consultation. We’ll assign you a dedicated TMS coordinator to help guide you through the insurance process from the very beginning.
2. Document previous treatment attempts
Insurance companies usually require evidence that you’ve tried other treatments before attempting TMS therapy. For Humana, this means you’ve either:
- Tried at least four antidepressant medications from at least two different classes during your current depressive episode, and haven’t experienced a clinically significant response. At least two of these trials must have been administered at a standard therapeutic dose over at least six weeks.
- OR you are unable to tolerate antidepressant medications due to unpleasant side effects or taking necessary medications that may interact negatively with antidepressants.
If you don’t have any documented proof of these treatment attempts, including dosage, duration, and response to treatments, our team can help you gather them. Sometimes, this means reaching out to your past providers to retrieve records.
3. Complete a standardized assessment
Humana requires you to complete standardized symptom assessments to track your progress before and during TMS therapy. For depression, this would be the PHQ-9.
We handle this assessment as part of your initial evaluation and ongoing treatment plan.
4. Submit a preauthorization request
Once we’ve confirmed that you’re eligible for TMS therapy, we’ll submit a preauthorization request to Humana. This is a detailed report that outlines why TMS is medically necessary for you. It includes things like:
- Your official diagnosis
- Prior treatment history and responses
- Evidence supporting the medical necessity of TMS
- Your proposed TMS treatment plan (usually 30 to 36 sessions).
At BestMind, we take care of this entire step for you. We’ll make sure you have all the documentation you need and that it’s submitted accurately and on time, so you have one less thing to worry about.
5. Understand your out-of-pocket costs
Depending on your individual plan, there might still be out-of-pocket expenses like co-pays, deductibles, or co-insurance amounts – even with insurance coverage. That means you may need to pay for part of the treatment yourself.
Before starting treatment, our team will review all the financial details with you to make sure you understand your exact coverage, expected costs, and available payment options.
FAQs: Humana insurance coverage for TMS therapy
Below are some frequently asked questions about Humana coverage for TMS therapy.
Does Humana cover TMS therapy?
Yes, Humana covers TMS therapy for adults and adolescents aged 15+ diagnosed with treatment-resistant major depressive disorder (MDD) when specific criteria are met.
What are the requirements to get Humana approval for TMS?
To be eligible for Humana insurance coverage for TMS, you must:
- Be 15 years or older
- Have an official diagnosis for MDD
- Show that you’ve tried at least four antidepressants from at least two different classes and failed to experience results
- Have no contraindications to TMS.
You also need a referral from a licensed psychiatrist.
Does Humana cover TMS re-treatment?
Yes, Humana covers TMS re-treatment if depressive symptoms have worsened by at least 50%, previous TMS treatment led to a 50% or greater improvement, and no new contraindications are present.
Does Humana cover TMS for adolescents?
Yes, Humana covers TMS therapy for teens aged 15 and over with depression.
Will I have out-of-pocket costs with Humana TMS coverage?
It depends on your specific Humana plan. Our team will help you verify your benefits and understand any out-of-pocket expenses that may apply before you start treatment.
Explore TMS therapy
TMS therapy can be a life-changing treatment for those with depression, and thanks to growing recognition from insurers like Humana, it’s more accessible than ever before.
We know that navigating insurance coverage can feel overwhelming, but you don’t have to do it alone. Our team at BestMind Behavioral Health is here to guide you through every step of the process, from verifying your benefits to handling documentation and preauthorization.
If you’re considering TMS therapy and want to find out if you qualify, contact us today. We’ll be happy to talk you through your coverage and discuss your options.
