Yes, many insurance plans, including Medicare, cover TMS therapy for major depressive disorder when you meet their medical-necessity criteria. In practice that means a confirmed diagnosis of depression and documentation that antidepressants (and usually therapy) have not helped enough. Most commercial and Medicare Advantage plans also require prior authorization before treatment starts. Coverage is decided plan by plan, so the answer for you depends on your benefits, not just on whether a clinic accepts your insurer.
This guide explains what insurers typically look for, how the authorization process works at our TMS therapy program in Folsom and Rocklin, what you might still owe after approval, and what to do if a request is denied.
What do insurers require before they cover TMS?
Transcranial magnetic stimulation (TMS) has been FDA-cleared for depression since 2008, according to the National Institute of Mental Health, and insurers treat it as an established treatment rather than an experimental one. That said, they reserve it for people who have already tried standard care. Most plans ask for some version of the following:
- A diagnosis of major depressive disorder, usually moderate to severe, documented with a standardized rating scale such as the PHQ-9.
- Antidepressant trials that did not work. Plans differ on how many trials they require, which medication classes count, and how long each trial must have lasted at a therapeutic dose. A documented intolerance (stopping because of side effects) may count, depending on the plan.
- A trial of psychotherapy, in many policies.
- A safety screening. Your clinician checks for implants in or near the head, seizure history, and other risks against the device's labeling and the plan's policy.
- An order from a psychiatrist who has evaluated you.
Your clinician gathers this history at the evaluation. Bring medication names, doses, dates, and the reason each one was stopped.
Does Medicare cover TMS therapy?
Yes, for major depressive disorder. In California, Medicare claims are handled by Noridian, and its TMS coverage policy covers left prefrontal TMS for adults with a confirmed diagnosis of severe major depressive disorder when one of the following applies: no meaningful response to antidepressant treatment in the current episode involving at least two medication classes; inability to tolerate antidepressants, shown by two trials from different classes with distinct side effects; a previous good response to TMS; or current treatment with electroconvulsive therapy (ECT) where TMS is a less invasive alternative. The policy also requires a trial of evidence-based psychotherapy that did not produce significant improvement, and that a psychiatrist who examined you order the treatment and supervise it. The policy itself has the exact wording.
Original Medicare generally does not require prior authorization for TMS, but your records must still meet the policy's criteria. Medicare Advantage plans must cover at least what original Medicare covers and usually add their own prior authorization step. Sacramento NeuroPsych Associates accepts Medicare; ask our office what your specific plan requires.
Which insurance plans does Sacramento NeuroPsych Associates accept?
We work with many commercial, Medicare, and Medi-Cal plans, including:
- Aetna
- Anthem Blue Cross PPO and HMO
- Blue Shield of California
- Carelon
- Kaiser
- Magellan
- Medicare
- Medi-Cal
- Optum Health
- Sutter Select
- United Healthcare
- Western Health Advantage
The complete list, including UMR, Web TPA, ComPsych, Adventist Health System, Partnership Healthplan of California, and Intel Connect Care, is on our insurance page.
One important distinction: accepting a plan means we can bill it. It does not mean TMS is covered under your particular policy. Each plan has its own TMS criteria, and some HMO plans require a referral from your primary care doctor before authorization can be requested. Ask our office whether your plan needs a referral or authorization, and when your benefits will be verified, before treatment is scheduled.
How does prior authorization for TMS work?
Most commercial and Medicare Advantage plans require prior authorization for TMS. Here is the usual sequence:
- Psychiatric evaluation. A psychiatrist confirms the diagnosis, reviews your treatment history, screens for safety issues, and decides whether TMS is appropriate.
- Records submission. The request to the plan includes your diagnosis, rating-scale scores, medication and therapy history, and the treatment order.
- Plan review. The insurer's reviewer compares your records with its criteria. Sometimes they request more information or a peer-to-peer call with your psychiatrist.
- Decision. If approved, the authorization typically covers an initial course of sessions over several weeks. Treatment can then be scheduled.
Review times vary by plan and by how complete the records are. Ask our office for a realistic estimate once your request is submitted.
What will I still pay if TMS is covered?
Approval is not the same as free. TMS sessions at our offices run about 20 to 30 minutes, typically five days a week over several weeks, so there are many visits; your care team will explain the schedule prescribed for you, including any taper. Your cost depends on:
- Deductible. If you have not met it for the year, early sessions may be billed to you until you do.
- Copay or coinsurance. Some plans charge a flat copay per visit; others charge a percentage. Multiplied across a full course, this is the number to ask about.
- Out-of-pocket maximum. If your plan has one, eligible covered expenses count toward it, and once you reach it the plan pays covered costs for the rest of the year. Original Medicare has no annual cap, according to Medicare's cost guidance; supplemental coverage may reduce your share.
- In-network status. Confirm the office and the billing provider are in network for your specific plan.
Ask our office for an estimate based on your benefits before you start. Our article on the TMS treatment timeline shows how the visits are spread out, which helps when you plan around work and copays.
Does insurance cover TMS for anxiety or OCD?
Usually not, or not yet. The FDA cleared TMS for obsessive-compulsive disorder in 2018, and some commercial plans now cover it, but many still consider OCD coverage case by case. Medicare in California does not cover TMS for OCD under the policy linked above. TMS for anxiety on its own is an off-label use and is generally not covered, although depression with anxiety symptoms is treated like depression for coverage purposes. If OCD or anxiety is your main concern, ask our office what your plan allows before assuming either way.
What if my insurance denies TMS?
A denial is not the end of the road. Steps that often help:
- Get the reason in writing. Denials usually cite a specific missing element, such as an undocumented medication trial or a rating-scale score.
- Ask about a peer-to-peer review. Your psychiatrist can speak directly with the plan's reviewer and add context.
- File an internal appeal with the plan, including any records that were missing.
- Request an external review. If the internal appeal fails and your plan is regulated in California, you can ask for an Independent Medical Review, which is free and has an outside doctor decide whether the treatment is medically necessary. Your denial letter says which regulator handles it: most HMO and many PPO plans go through the Department of Managed Health Care (Help Center 1-888-466-2219), and some PPO and other policies go through the California Department of Insurance. Medicare has its own appeal process.
Ask our office what the denial said and which of these steps makes sense.
TMS in Folsom and Rocklin
Sacramento NeuroPsych Associates provides TMS with MagVenture equipment at our Folsom and Rocklin offices. Dr. Harjot Sekhon and Dr. Abhijit Ramanujam are certified in TMS. There is no anesthesia or sedation, so most patients drive themselves and go back to work or school after a session. If you notice side effects like a headache or lightheadedness, follow your clinician's advice. Our article on whether TMS is effective for depression summarizes the research if you want to understand what the insurer is approving.
If you are in crisis or thinking about harming yourself, call or text 988 (Suicide and Crisis Lifeline) or call 911.
Frequently asked questions
How many TMS sessions will insurance approve?
Authorizations usually cover an initial course of sessions over several weeks, often with a taper at the end. The exact count depends on the plan and the protocol your psychiatrist orders. Ask our office what was approved before you start.
Does insurance cover repeat or maintenance TMS?
These are two different questions. A new course after a relapse may qualify under a plan's retreatment criteria; Medicare's California policy, for example, allows it if you met the original criteria, improved by more than 50 percent on a rating scale the first time, and later relapsed. Scheduled maintenance sessions have separate rules, and some commercial plans do not cover them. Ask about both before your first course ends so there is no gap if you need more treatment.
Do I have to stop my antidepressant to qualify for TMS?
No. Insurers want to see that medication was tried, not that it was stopped. Many patients continue their medication during TMS. Never change a medication without talking to your prescriber.
Does Medi-Cal cover TMS?
Medi-Cal and the managed-care plans that administer it have their own rules, and they change. We accept Medi-Cal, so call us and we will check what your plan currently allows.
Can I pay for TMS without insurance?
Yes. If your plan denies coverage or you prefer not to use it, ask our office for a self-pay estimate that spells out what is included.
Take the next step
The fastest way to find out whether your insurance covers TMS is a psychiatric evaluation, where we review your history and check your benefits. Schedule an appointment or call (916) 473-2235 to get started.
