Introduction
Transcranial Magnetic Stimulation (TMS) has become one of the most powerful tools in modern psychiatry—offering real hope for patients with treatment-resistant depression. But while the clinical outcomes are clear, the path to treatment is often blocked by something far more frustrating: insurance confusion.
Patients ask: “Is TMS covered?”
Clinics wonder: “How do we get it approved?”
And too often, both are met with delays, denials, or dead ends.
The good news? TMS is covered by most major insurance providers, including Medicare. But approval depends on knowing exactly what each payer requires—and how to navigate the process strategically.
Here’s what you need to know.
1. Yes, Insurance Covers TMS—But There’s a Catch
TMS is FDA-approved for depression and obsessive-compulsive disorder (OCD), and all major commercial insurers, plus Medicare, offer some level of coverage.
But coverage ≠ access.
Each plan has its own medical policy, outlining the clinical criteria that must be met before TMS is approved. These can include:
- Proof of treatment-resistant depression (typically 2–4 failed antidepressants)
- A history of talk therapy or counseling
- A formal diagnosis using validated scales like PHQ-9 or GAD-7
- Documentation of psychiatric evaluation
- No contraindications (e.g., metal in the head, active seizures, certain cardiovascular conditions)
Even with all of this, you still need to file a prior authorization—and do it right.
2. Medical Policy Requirements Vary by Insurer and State
There’s no universal playbook for TMS coverage. Aetna, Blue Cross, UnitedHealthcare, Medicare—all have slightly different expectations, and these often vary by region.
What’s accepted in California may be denied in Illinois. That’s why it’s critical to:
- Keep a cheat sheet of top payers’ current TMS policies
- Align your intake process with insurance-friendly screening questions
- Stay up-to-date on annual policy updates (these often change every January)
Clinics that know how to tailor their paperwork to the carrier get approvals faster—and lose fewer leads in the waiting game.
3. The Prior Authorization Process Is Where Most Clinics Get Stuck
Submitting a prior auth isn’t just about checking boxes—it’s about storytelling that aligns with policy.
The most common reasons for denials include:
- Incomplete or vague medication history
- Missing psychotherapy documentation
- Inconsistent provider notes
- Incorrect CPT codes (e.g., using 90867 instead of 90868 or 90869)
Every step of the TMS workflow—from intake forms to VOBs—needs to be designed around getting the payer to say “yes.”
At Rise4, we help clinics structure everything from patient intake to prior auth submissions to ensure clean files, fast approvals, and minimal rework.
“If you don’t know what your top three payers require, you’re setting your team—and your patients—up for unnecessary delays.”
4. Medicare Covers TMS—But It’s Not a Free Pass
Medicare has its own unique process, often more forgiving than commercial plans, but still requires:
- A diagnosis of Major Depressive Disorder
- Clear documentation of medication failure and psychotherapy
- Medical necessity outlined in the evaluation notes
Many clinics assume Medicare will automatically approve treatment—but forget to include key eligibility statements or use inconsistent documentation, leading to delays.
Tip: Always include documentation of treatment-resistant status, even when you think it’s implied.
Conclusion
Insurance shouldn’t be the barrier between a patient and life-changing treatment. Yet for many TMS clinics, it is.
The difference between a clinic that succeeds at scale and one that stagnates often comes down to this: Do you understand the coverage game?
With the right systems, screening questions, and documentation workflows, TMS can be reliably approved—and your clinic can thrive without constantly chasing paperwork.
If you’re tired of authorization delays, missed revenue, and confused patients, it’s time to get proactive.
