Insurance Coverage of TMS
Many major insurance plans now regard TMS as a covered benefit, usually subject to Prior Authorization. Obtaining Prior Authorization requires that we provide your insurer with detailed documentation of your previous treatments for depression. The documentation must show that you have had extensive antidepressant medication trials meeting the insurer’s criteria. Insurers may also require psychotherapy specifically addressing depression. If the documentation submitted does not meet their criteria, they will decline to authorize coverage for treatment.
Because TMS is a relatively expensive treatment compared to medications, insurers frequently use Prior Authorization (PA) criteria that are quite demanding. For example, insurers may deny authorization for TMS if a patient has not tried at least 4 different antidepressant medications from different classes, along with at least 2 medication augmentation strategies, and had psychotherapy specifically targeting depression. The insurers require us to submit records showing the dates that the medications were tried, and what doses were given. If the treatment information we supply does not meet their criteria, they will deny authorization.
How We Manage the PA Process
Prior to scheduling your initial consultation, with your permission we will ask your psychiatrist or other treating practitioner to provide us with a detailed history of treatments for depression that have been tried to date. We supply your practitioner with a concise Depression Treatment History form and guidelines that make clear exactly what information is needed. This will usually require about 15 minutes. We then review your treatment history, and advise you regarding the likelihood that your insurer's PA criteria have been met. If PA criteria have not been met, we can advise your psychiatrist as to what additional treatments might satisfy the insurer.
Self Payment for TMS
We have worked with many patients who choose to self pay for their treatment with us. We offer a significant prepayment discount for those who wish to purchase a “package” including the Motor Threshold session, followup meeting with the doctors, and a specified number of TMS treatment sessions.