Is TMS Covered by Insurance? Understanding Your Options

Transcranial Magnetic Stimulation, or TMS, has become a life-changing option for people struggling with treatment-resistant depression and certain anxiety conditions. But one of the first questions many patients have is simple: Is TMS covered by insurance?

The short answer is that many insurance companies do cover TMS therapy, but the details can vary based on your plan, your diagnosis, and the type of TMS you’re considering. At Goolsby and Associates, we want you to be informed about TMS and how your insurance carrier may cover this treatment. We will break down how insurance coverage works for both standard TMS and accelerated TMS, both of which we offer to clients in the North Georgia area. We want to inform you about what to expect during the approval process and the essential questions to ask your insurance provider before starting treatment.

Understanding What TMS Is

Before discussing coverage, it is helpful to understand what TMS actually does. TMS is a non-invasive, drug-free treatment that uses magnetic pulses to stimulate areas of the brain involved in regulating mood. It is typically used for major depressive disorder that hasn’t improved with medications or therapy.

Standard TMS is the traditional approach. Here at Goolsby and Associates, sessions typically last between 5 and 30 minutes, depending on your individual needs, and are usually held five days a week over a period of four to six weeks. It is the most widely covered by insurance because it aligns closely with the long-established treatment protocol used in major clinical studies.

We now offer Accelerated TMS, which differs from the standard treatment protocol in duration and session length. This method involves multiple sessions per day over a shorter period, often just five days. It is based on newer research and offers the benefits of TMS in a condensed timeline. While it is growing in popularity, coverage varies more widely because not all insurers classify accelerated protocols as standard of care.

Is Standard TMS Covered by Insurance?

In most cases, yes. Standard TMS is widely accepted by major insurance companies, including commercial plans, Medicare, and many Medicaid plans. However, you must usually meet specific criteria for coverage. These commonly include

A diagnosis of major depressive disorder
Documentation that you’ve tried and not responded well to antidepressant medications
A history of trying talk therapy or being unable to participate in therapy
A recent clinical evaluation confirming that TMS is appropriate

If these requirements are met, your clinic typically submits a prior authorization request to your insurance provider. This step is crucial. It gives the insurance company the opportunity to review your medical history and determine whether the treatment will be covered.

The good news Many patients who meet the criteria are approved. Some insurers even have dedicated TMS review departments to make the process more efficient.

Is Accelerated TMS Covered by Insurance?

Coverage for accelerated TMS is more complicated. Although research supports the effectiveness of accelerated protocols, many insurance companies still view them as a relatively new treatment approach. Some insurers consider accelerated TMS investigational, while others may approve it under certain circumstances or on a case-by-case basis.

Patients interested in accelerated TMS should be prepared for the possibility of:

Limited or no coverage
A need for additional documentation or justification
Potential out-of-pocket costs

If accelerated TMS is your preferred option, we recommend checking your benefits early, as it can help you avoid any surprises. Our office can assist you with this process and help you determine the right treatment option based on your needs and insurance coverage.

Understanding Prior Authorization

Whether you’re pursuing standard or accelerated TMS, the prior authorization process is the key step in determining coverage. During this process, the insurance company reviews:

Your diagnosis
Your medication history
Your previous treatment attempts
Your current symptoms
Your provider’s justification for TMS

It’s not unusual for an insurance provider to request additional documentation, such as notes from your therapist or psychiatrist. This can add some time to the approval process, but it’s part of ensuring that TMS is medically necessary according to your plan.

Here is an example of a prior authorization request from Aetna. Although this document may differ from your own insurance company's policies, it can serve as a guide.

If a request is denied, your provider can often appeal the decision. Appealing doesn’t guarantee approval, but many patients do receive coverage after a second review.

What Patients Should Ask Their Insurance Providers

Understanding your insurance benefits can be confusing, so it helps to have a clear list of questions when you call your insurance company. Here are the most important things to ask:

Do you cover standard TMS therapy for major depressive disorder?
Do you cover accelerated TMS protocols?
What are the criteria I must meet to be eligible for coverage?
Will I need to try additional medications before qualifying?
Is prior authorization required?
What documentation do you need from my provider?
What are my copays, deductibles, or out-of-pocket costs?
Is there a limit on the number of TMS sessions that can be covered?
Are follow-up or maintenance sessions covered?
Is my provider in network?
If not, do you offer out-of-network benefits?

Taking notes during your call is helpful. Ask for the representative’s name and a reference number for the conversation. This can make the approval process smoother if questions come up later.

What to Expect If You Are Approved

Once your insurer approves TMS, we will schedule your treatment sessions. For standard TMS, this means visiting the clinic almost daily for several weeks. Many people begin to feel improvement after the first two to three weeks, but progress can vary.

If you’re doing accelerated TMS, your schedule will be more intense, with multiple sessions in a single day. Although the overall treatment time is condensed, the cumulative number of treatments is similar to standard TMS protocols.

Insurance typically covers the treatment itself, but you may still be responsible for copays or coinsurance based on your plan. Your provider’s billing team can help you understand these costs ahead of time.

What to Do If You Are Not Approved

If your insurance denies coverage, don’t panic. There are a few steps you can take:

Request that your provider file an appeal
Provide any missing documentation
Ask your insurer for the specific reason for the denial
Explore self-pay rates or payment plans
Ask if you qualify for financial assistance programs

Many denials are due to missing paperwork or incomplete medical history. Once the insurer has all the information, coverage may still be granted.

There is always hope.

TMS is a powerful treatment option for people who haven’t found relief from traditional therapies. Standard TMS is widely covered by insurance, while accelerated TMS coverage varies depending on your plan and insurer. The best way to understand your options is to contact your insurance provider early, ask the right questions, and work closely with your TMS clinic’s authorization team.

By being informed and proactive, you can navigate the insurance process confidently and focus on what matters most: feeling better and moving forward with your mental health treatment.

At Goolsby and Associates, we want to see you thrive. We will work with you to determine your coverage. If TMS sounds like a treatment worth exploring, please do not hesitate to contact our offices today.