TMS Therapy: Insurance Coverage Guide

Transcranial Magnetic Stimulation (TMS) therapy is a non-invasive, FDA-approved treatment that can help relieve depression, especially when traditional medications and therapies haven’t worked in the past. The treatment uses magnetic pulses to stimulate underactive regions of the brain, helping ease symptoms of major depressive disorder (MDD) and treatment-resistant depression (TRD) without the need for sedation or the systemic side effects of medication.

Besides depression, TMS has also been shown to help with other mental health conditions, and is FDA-approved to treat obsessive-compulsive disorder (OCD) and smoking cessation.

In this guide, we’ll walk you through what to know about TMS therapy insurance coverage, including how it works, the steps involved, and how to get TMS therapy coverage from your insurance provider.

How does TMS work?

Before we get into the specifics of TMS insurance coverage, let’s look a bit closer at how this innovative therapy works.

TMS uses magnetic pulses to stimulate specific areas of the brain involved in mood regulation and other executive functions. These pulses help modify brain activity and improve communication between neurons, which can reduce the severity of symptoms in conditions like major depression, anxiety disorders, OCD, and more.

What’s involved in a TMS session?

TMS is delivered in a medical office or outpatient clinic by trained technicians and physicians specialized in the treatment. It’s non-invasive, which means there’s no need for sedation or anesthesia. During each session, an electromagnetic coil will be positioned over your scalp, delivering targeted pulses to areas of the brain where activity is underactive or imbalanced.

Your first TMS appointment involves what’s called ‘brain mapping’. In this first session, the technician will carefully calibrate the TMS device to determine your individual tolerance level (known as your motor threshold). This helps tailor the treatment while keeping it as effective and comfortable as possible.

Each TMS session lasts approximately 20 minutes, and there’s no downtime or recovery afterwards. That means you’re free to resume your usual daily activities, including driving or going to work or school.

Is TMS therapy covered by insurance?

Yes, most major insurance companies cover TMS therapy for major depressive disorder (MDD) and treatment-resistant depression (TRD). That said, coverage details can vary depending on the specific insurance plan and provider, so it’s important to understand the factors that determine your eligibility.

In order for TMS therapy to be covered by insurance, you need to meet several conditions:

The treatment must be included in the insurance plan’s covered treatments
The provider must be in-network
The treatment must be considered medically necessary.

It’s important to note that coverage policies for TMS are still evolving, however most large insurers now recognize the value of TMS therapy. If you’re considering TMS, it’s a good idea to:

Contact your insurance provider: You can call member services or use your plan’s online portal to check if your preferred TMS provider is in-network. Out-of-network providers aren’t covered by insurance, although some may contact your insurance provider to negotiate case-by-case coverage.
Ask the TMS provider: Most clinics, including us here Psychiatry Treatment Centers, can help verify insurance benefits on your behalf and explain what’s covered.
Explore carve-out plans: Some carriers offer something called a ‘carve-out plan’, which allows you to get a separate insurance plan for services that aren’t included in your traditional policy. Don’t be afraid to ask your provider if they offer this option.

How to get insurance coverage for TMS therapy

It might feel overwhelming trying to navigate insurance coverage for TMS, but it’s actually more straightforward than it seems. Below, we outline the steps involved so you know what to expect.

1. Start with a formal diagnosis

To qualify for insurance-covered TMS therapy, you’ll need a formal diagnosis from a licensed mental health provider. Most insurance plans cover TMS for moderate to severe major depressive disorder (MDD) and, in some cases, obsessive-compulsive disorder (OCD). The diagnosis must follow criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM) and be backed by clinical evaluation.

If you don’t have a diagnosis yet and are experiencing debilitating symptoms, please reach out to a TMS provider to schedule a consultation. They will help confirm if TMS is right for you and start the process of getting you approved for insurance coverage. Contact our team at Psychiatry Treatment Centers to get started.

2. Get the documentation you need

Most insurance providers will need evidence that you’ve tried standard treatments without success before they approve TMS. If you have depression, that usually means trying at least two different antidepressant medications (from separate drug classes) and participating in psychotherapy. For OCD, it might involve trying medications and specialized therapy approaches like exposure and response prevention (ERP).

Make sure your provider has records showing which medications or therapies you’ve tried, how long you’ve used them, and what outcomes you experienced (if any).

3. Complete standardized assessments

Insurance plans will often ask you to assess your symptoms both before and after TMS treatment to track your progress. This might include using tools like the PHQ-9 for depression or Y-BOCS for OCD, both of which are usually done as part of your TMS evaluation process.

4. Get preauthorization

Once your eligibility has been confirmed, your TMS provider will submit a preauthorization request to your insurance company. This is a formal submission that explains why TMS is medically necessary and includes details like your diagnosis, treatment history, and planned course of TMS sessions (usually 30-36 treatments).

Don’t worry, your TMS clinic will handle this step for you to make sure everything is submitted correctly and on time.

5. Check any out-of-pocket costs

Some patients might still have out-of-pocket costs, even with insurance. At Psychiatry Treatment Centers, we can help you understand your specific plan details and walk you through any expected costs before you start treatment, so you don’t have to worry about any unexpected surprise bills.

What is medical necessity for TMS?

You might have noticed us saying that insurance providers will require proof that TMS therapy is medically necessary before they approve coverage. But what does that mean?

Medical necessity means that TMS is considered a clinically appropriate and essential treatment based on your specific diagnosis and symptoms. In other words, it’s not an optional or experimental therapy.

There are two ways to demonstrate medical necessity:

Qualifying diagnosis: This usually involves confirming conditions like MDD or OCD through a formal clinical evaluation.
History of unsuccessful treatments: This involves showing that other standard treatments (like medications or psychotherapy) have been tried without sufficient success. It tells insurance providers that TMS isn’t just reasonable, but necessary to address your ongoing symptoms.

Your TMS provider will carefully review your medical history, treatment records, and current symptoms to determine if you meet the criteria for medical necessity. They’ll then compile and submit all the required information to the insurance company as part of the preauthorization process we outlined earlier.

How much does TMS therapy cost?

The cost of TMS therapy can vary widely and will usually depend on your insurance plan. Even if you have insurance coverage, it’s common to sometimes have some out-of-pocket expenses, but again, the exact amount can differ case by case.

Some factors that can influence the cost of TMS include:

Deductible: This is the amount you need to pay out of pocket each year before your insurance starts covering services
Copay: This is a fixed fee you pay for each TMS session as determined by your insurance plan
Coinsurance: This is a cost-sharing arrangement where you pay a percentage of the treatment cost and your insurance covers the rest (e.g. you pay 20% and your insurance pays 80%).

In some cases, insurance might cover the full cost of TMS. In others, you might need to cover part of the expenses yourself. The best way to know for sure is to work with a TMS provider who can contact your insurance company, check your benefits, and help you understand your expected costs.

Explore TMS therapy

If you’d like to explore TMS therapy or another mental health treatment, our friendly and compassionate team at Psychiatry Treatment Centers is here to help. We can help you explore your options, understand your benefits, and guide you through the necessary steps to get the coverage you need.