Is TMS Covered By Insurance: What Is The Treatment Cost?

TMS and Insurance

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What is TMS Therapy?  

Depression, also known as the silent epidemic, affects more than 16 million adults in the USA, with more cases being reported each year. Typical treatments for depression, like other mental health diagnoses, are psychotherapy and antidepressant medications, among other treatments, however, they don’t always suffice nor are they always effective in the treatment of depression. The process of psychotherapy and antidepressant treatment takes time and the antidepressant medications often come along with significant, often harsh side effects.

However, there’s a newer and more convenient treatment for relief from depression.

Transcranial Magnetic Stimulation (TMS), commonly known as TMS therapy, is a depression treatment that uses a powerful electromagnetic coil to stimulate tissues of the brain which are known to contribute to mood control and depression. As its name, Transcranial Magnetic Stimulation suggests, the procedure works by attaching an electromagnetic coil on the patient’s forehead and releasing a series of repetitive, focused magnetic pulses to stimulate nerves in the brain, particularly those responsible for one’s mood.

TMS therapy requires no sedation and is always conducted officially in a clinician’s office. It has also been FDA-approved as a reliable option for the treatment of various forms of depression including, depression since 2008, making it one of the most sought-after treatments for depression.

TMS Treatment Compared to Antidepressants Treatment

The STAR*D study is the largest antidepressant study ever conducted, enrolling more than 4,000 patients diagnosed with major depressive disorder (MDD) to understand how effective antidepressants are in relieving depressive symptoms. Researchers found that after 14 weeks of trying to treat MDD with two types of antidepressants (at levels three and four of treatment), patients were less likely to achieve remission. This study clearly shows that some patients may be resistant to traditional depression treatments like antidepressant medications, or have treatment-resistant depression.

On the other hand, the Carpenter study was to evaluate the effectiveness of TMS  for patients diagnosed with MDD who had tried on average 2.5 antidepressant medications without seeing an improvement of the depressive symptoms. 

At the end of the curated six-week treatment period, 26.5 to 28.7 percent of patients reported remission and 41.5 to 56.4 percent reported a positive response (improvement in depressive symptoms) to TMS. This was a higher percentage as compared to the patients in the STAR*D study, where after the patients had tried two to three antidepressants, the remission rate was at 7 to 14 percent.

These results suggest that is a patient has tried several different antidepressants for the treatment of MDD without achieving remission or seeing an improvement in symptoms, TMS is more likely to relieve depressive symptoms than trying another antidepressant and within a shorter time frame, making it more cost-effective than antidepressant medication.

TMS Treatment Cost Compared to the Cost of Antidepressants Treatment

Many patients with diagnosed MDD find that the cost of TMS treatment ends up being comparable to the cost of antidepressants. Even with insurance coverage for prescription medications, antidepressants can cost up to $150 per month or $1,800 over the course of a year. TMS could cost as low as $370 for an entire 9-week course of treatment, with results lasting over a year in 62.5% of patients.

health insurance and tms treatment

Do Insurance Companies Cover TMS Therapy Cost?

As a rule, insurance companies won’t and don’t pay for services or procedures unless the service or procedure is considered medically appropriate or necessary. While every insurance company’s policies are different, the following general criteria typically dictate whether TMS therapy will be covered:

  • You’ve been clinically diagnosed with moderate-to-severe Major Depressive Disorder (MDD).
  • You have documentation that at least two (sometimes four) depression medications of different classes have not been helpful.
  • You made an adequate attempt at talk therapy known to be effective for treating depression but showed little improvement.

What is Not Covered by Insurance for TMS Treatment?

While TMS is a safe and effective treatment for many conditions other than depression, Insurance coverage for TMS therapy does not include the treatment of the following diagnoses:

  • Post-traumatic stress disorder (PTSD)
  • Obsessive-compulsive disorder (OCD)
  • Traumatic brain injury (TBI)
  • Bipolar Disorder or BPD
  • Anxiety
  • Attention-Deficit/Hyperactivity Disorder or ADHD
  • Tinnitus
  • Migraine headaches
  • Chronic pain

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Factors Affecting Insurance Coverage for TMS Cost

TMS therapy is considered a cost-effective treatment due to its proven long-lasting results for the treatment of depression. However, the cost of TMS therapy can vary greatly from patient to patient.

All major insurance companies do cover the cost of TMS therapy for the treatment of depression, but the cost of TMS therapy covered by the insurance varies based on the plan and insurance company. Insurance coverage varies among the different insurance companies.

Insurance companies cover TMS therapy typically when the patient has tried at least 4 antidepressants from 2 different drug classes (SSRIs, SNRIs, TCAs, MAOIs, or atypical agents) without successful symptom control.

Sometimes, the full cost of TMS therapy is covered, or patients may be required to pay a copay or deductible, coinsurance, or both.

For patients with a copay, they will pay their copay each time a TMS treatment session is completed. Insurance companies define the number of TMS treatment sessions covered by the specific insurance policy, and the number defined often falls between 20 to 40 sessions.

In cases where the patient has a deductible, they are required to cover the cost of TMS therapy until their deductible cost equivalent is met. Once the deductible is met, the patient’s insurance company will cover a portion or 100% of the cost of their TMS therapy sessions until recovery.

With the third option,co-insurance, the patient is responsible for a portion of the cost of TMS therapy. Meaning they share the payment with their insurance company. For instance, if an insurer covers 90% of the cost of TMS therapy, the patient will be responsible for the remaining 10%.

Is TMS Covered By Medicare And Medicaid?

The straight short answer is yes, but the coverage by Medicare and Medicaid may vary depending on your specific Medicare or Medicaid plan.

Medicare is a federal program that provides health coverage for medical services and procedures for persons 65+ or under 65 that have a disability, no matter the income.

Medicaid is both a state and federal program that provides health coverage for persons with a very low income. When eligible for both Medicare and Medicaid (dually eligible) they often work together to provide health coverage with lowered costs.

If all the requirements set by the Medicare or Medicaid plan are met, Medicare may pay for 80% of the treatment cost. However, you’ll still be responsible for the annual deductible before any coverage kicks in, and you may also need to cover the remaining 20% of the cost, as well as your monthly premium payments.

The requirements for basic Medicare coverage of TMS therapy are similar to what most insurance companies require, only there is one extra:

  • The treatment provider must be able to accept Medicare’s approved reimbursement as full payment for the service.

How to Improve Your Chances at Insurance Coverage for TMS

Ultimately, insurance providers have the final say on how much they’ll pay for medical services. Although you can’t control their decisions, you can often improve your odds of getting coverage. Here are some tips and recommendations to help your TMS therapy qualify for insurance coverage:

Show a Well-Documented History of Previous Treatment Attempts.

Having accurate treatment records is essential, most especially if you’ve stopped taking a medication due to side effects or other complications. Make sure to report any progress (or lack thereof) honestly to your doctors so that they can understand these issues accurately and document your experience clearly.

Follow Each Treatment as Completely as Possible.

Many insurance requirements look for eight consistent weeks of talk therapy or medication use, despite it being normal to forget to take medication once in a while or sometimes to make every appointment. When trying other treatments before considering TMS, follow your treatment recommendations as best you can.

Recognize Other Conditions or Circumstances That May Limit Your Coverage.

Each insurance company has its own list of why they might not cover a treatment or procedure. Some may be short-term situations that can change; others may be a medical diagnosis that you have no control over. Contact your provider to help you understand the requirements.

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