Is TMS covered by Insurance?
Most major commercial insurance companies (e.g., United Healthcare, Cigna, Aetna, BCBS) will cover TMS treatment. However, The Center for Cognitive Brain Health at USP is out-of-network with most insurance companies except Medicare. This means that you will need out-of-network benefits if you want insurance to cover TMS. The basic criteria to qualify for insurance coverage is:
- You are diagnosed with Major Depressive Disorder
- You’ve tried at least 2 -4 different antidepressants without significant improvement
- You have tried psychotherapy without significant improvement
It is important to note that other insurance companies can be very meticulous when assessing coverage for TMS therapy. If our clinicians think you are a potential candidate for TMS, we will contact your insurance company to verify that they will cover your TMS treatment. Coverage varies per insurance company and it can take some time to receive approval. As a result, we suggest making an appointment as soon as possible in order to put the process in motion.
What if I have Medicare?
We are in-network for Medicare, but it comes with some caveats. Medicare will cover TMS therapy if you meet the above criteria and will pay for 80% of the cost of treatment. The remaining 20% will be billed either to you or to your secondary insurance, if applicable.
What about insurance coverage for conditions other than depression, such as anxiety or OCD?
OCD was recently FDA-approved in August 2018, but most insurance companies have yet to offer coverage as it currently stands. Other treatable conditions, such as anxiety, PTSD, and smoking cessation, are considered “off-label” treatments, meaning it has not yet been FDA-approved. As a result, insurance companies will often not cover treatment for these conditions. The one workaround for off-label treatment is to pay out-of-pocket, which would bypass insurance guidelines.