The coping process of depression or anxiety is tiring, not to mention the fact that the treatment methods do not seem to produce any results. Transcranial Magnetic Stimulation (TMS) therapy appears to be a new ray of hope for many people as a non-invasive and drug-free means of treating mood disorders. However, there is one question that most people are wondering and that is: Does Medicare cover TMS therapy?
Being a Medicare patient or having someone who is one, knowing what your Medicare coverage of TMS will cover can be of massive importance when deciding how to treat someone. We are going to deconstruct what TMS is, how it works, whether TMS is covered under Medicare to address depression, and also what you can do if it is not.
What Is TMS Therapy and Who Needs It?
Overview of Transcranial Magnetic Stimulation (TMS)
Transcranial Magnetic Stimulation (TMS) is a non-invasive, FDA-approved treatment method that employs magnetic pulses in order to stimulate mood-related areas of the brain. It is applied mostly when the standard therapy options, such as antidepressants or psychotherapy, are ineffective.
A magnetic coil is placed over the scalp during one of the sessions. This coil transmits mild pulses that stimulate nerve cells in the areas of the brain that are connected with mood and emotion. In the long term, this stimulation may alleviate the symptoms of depression, anxiety, and other mental disorders.
TMS therapy is safe, efficient, and does not necessitate anesthesia or medication. The sessions usually take approximately 20-40 minutes, and the patients can resume regular activities right after the performance.
Conditions Treated by TMS (Depression, Anxiety, etc.)
The most frequent applications of TMS therapy are in treating:
- Major Depressive Disorder (MDD) – more particularly among individuals who are non-responsive to antidepressants.
- Anxiety Disorders – with generalized anxiety disorder and panic disorder.
- Obsessive-Compulsive Disorder (OCD) – in a few instances, when drugs are unsuccessful.
- PTSD – early research shows promising results.
- Bipolar Depression – to stabilize the mood.
Due to the high success rate and low side effects, most patients state that it is life-changing. But the most significant issue is how to cover it and whether it is covered by Medicare TMS.
Why Medicare Patients Might Consider TMS
Depression can be a problem with older adults or those on disability. Regrettably, the side effects of medication may be worse in this group. This is why most Medicare patients consider TMS treatment – it is a medication-free treatment method that is easy and capable of reinstating hope and stability in patients.
The good news? Under certain conditions, Medicare will cover TMS therapy for depression. Let’s look at how that works.
Does Medicare Cover TMS Therapy?
Medicare Coverage for TMS
Yes – TMS therapy is covered by Medicare for individuals who have major depressive disorder (MDD) and pass the required criteria. The procedure has to be considered medically necessary and has to be performed by a qualified individual.
Part B of Medicare typically supports outpatient treatment of mental health services, such as TMS treatment, as other treatment options fail. This implies that you will pay 20% of the negotiated amount of Medicare, plus paying the Part B deductible annually.
Concisely, TMS Medicare coverage exists, but it will depend on your diagnosis, the provider and treatment background.
Is TMS Covered by Medicare for Depression?
Yes, but with conditions.
To be issued with Medicare TMS coverage, you need to:
- Diagnosed with Major Depressive Disorder (MDD).
- Tried and failed at least two varieties of antidepressant drugs.
- Have done psychotherapy (such as CBT) in vain.
- Provide a recommendation for TMS by a Medicare-approved psychiatrist.
In case these conditions are satisfied, TMS is paid for by Medicare through Part B benefits in case of depression.
Medicare TMS Coverage Guidelines and Eligibility
Medicare TMS requires the following when it comes to approval:
- Recorded treatment-resistant depression.
- At least 4 weeks of failed antidepressant trials.
- No history of seizures or metal implants around the head.
- Treatment must be managed by a licensed psychiatrist.
- Application of a TMS device approved by the FDA.
You are expected to meet all these points, whereby the cost of your Transcranial Magnetic Stimulation treatment should be covered under Medicare.
How Much Does TMS Therapy Cost Without Medicare?
Average Out-of-Pocket Expenses
Without insurance, TMS treatment costs between $300 and $500 per session. An entire course of treatment (typically 30-36 sessions) may cost all out of pocket in the range of $9,000-15,000.
This is why it is so critical to find out how Medicare covers TMS; it will save thousands of medical bills.
TMS Reimbursement Rates and CPT Codes
Clinics on Medicare billing would use CPT code 90867 in the first TMS treatment and 90868 in the subsequent treatments. Based on your area and health care provider, Medicare will pay a part of the approved cost of each code.
The benefits of your TMS Medicare cover will vary according to your plan, the status of your deductible, and your location. Never forget to check with your treatment provider regarding your rate of reimbursement.
Comparing Medicare Coverage vs. Private Insurance
Although Medicare includes TMS as a treatment for depression, most private insurance plans extend further in some cases, including TMS as a treatment of anxiety or OCD.
There can also be the case of private insurance, which offers:
- Lower copays
- Faster pre-authorization
- Extended mental health insurance.
Nevertheless, the TMS coverage of Medicare is among the surest choices among the elderly and the disabled who qualify based on the clinical requirements.
Other Insurance and Government Programs Covering TMS
Does Medicaid Cover TMS Therapy?
The Medicaid coverage of TMS therapy varies by state. There are those states that will cover depression fully and some that will demand extra documents. The best bet would be to call the Medicaid office of your state to find out.
Does Tricare Cover TMS?
Yes, Tricare will cover TMS therapy for service members and veterans who are diagnosed with Major Depressive Disorder. Similar to Medicare, it needs prior approval and evidence that other forms of treatment have failed.
What About Other Private Insurance?
TMS therapy is now covered by most major insurance companies as a treatment option to treat patients with treatment-resistant depression such as Aetna, Blue Cross Blue Shield, and UnitedHealthcare, among others. Some address the case-by-case TMS to anxiety.
Before you begin the treatment, always confirm the coverage with your provider.
How to Get Medicare to Cover Your TMS Treatment
Steps to Get Pre-Authorization
TMS will require a pre-authorization procedure before the first session. Here’s how:
- Visit your psychiatrist. Get a diagnosis and ensure that you have a diagnosis of depression.
- Provide medical records. Demonstrate the use of previous treatments and unsuccessful antidepressant therapy.
- STAMP out authorization paperwork. Your provider will provide the documents to Medicare.
- Wait for approval. Upon approval, you are free to proceed with your TMS.
Working With Providers and Therapists
Ensure that you obtain a TMS provider that is approved under Medicare. Medicare TMS coverage would be done by clinics that are well-versed in billing, paperwork, and eligibility checks.
Your TMS therapist must also provide an idea of what to expect from the treatment and how to monitor your progress.
Documentation and Medical Necessity
To be covered by Medicare TMS, you will be required to have clear documents that indicate:
- Your diagnosis of mental health.
- Your treatment history
- Physician recommendations
This paper demonstrates that TMS is clinically necessary, and hence, it is more likely to be approved and reimbursed.
Alternative Options If Medicare Doesn’t Cover Your TMS
Financing Plans and Payment Assistance
In case you are not eligible to get the Medicare cover, most TMS clinics have payment options that can make their treatment more affordable. Some even cooperate with financing firms that allow one to pay in monthly instalments.
Advantage TMS and Other Programs
Others have Advantage TMS initiatives that assist patients in seeking insurance or other funding options. Those programs are usually accompanied by sliding-scale rates and financial assistance.
Exploring Other Non-Covered Treatments
Assuming your condition is not covered by Medicare as part of TMS: Ask your physician about:
- rTMS (repetitive TMS) is the same as TMS except different frequency.
- ECT (Electroconvulsive Therapy)- in severe, treatment-resistant depression.
- Another alternative in quick symptom relief is ketamine therapy.
Final Thoughts
Benefits vs. Costs
TMSI therapy is potentially life-changing for patients who meet the eligibility criteria. The cost can be easily overshadowed by the benefits, such as less depression, a better mood and quality of life.
The coverage of Medicare will enable an increase in the number of seniors and disabled adults who can obtain this revolutionary treatment without feeling the financial pressure that it might cause.
When to Consider TMS Therapy
TMF therapy might be an option in case you have tried several antidepressants and therapy with little or no success. It is safe, effective, and has Medicare coverage in case it is found to be medically necessary.
Talking to Your Doctor About Your Options
The first step is to have a candid talk with your psychiatrist or primary care provider. Inquire about the Medicare TMS guidelines, whether you are eligible and what local clinics provide covered services.
Your doctor may also assist with pre-authorization documents and referrals to a certified practitioner of TMS in your area.
Conclusion
Medicare includes TMS in depression under Part B, when it is medically required and properly recorded. Although this might not cover additional conditions at this time, it is a massive step in the right direction for patients who have had a hard time with medication-resistant depression.
TMS treatment is a non-invasive, advanced treatment of mental health – a way of restoring one’s happiness and peace of mind.
To explore more about Medicare and TMS treatment options, visit Minds Over Matter today!
FAQs
Yes. Medicare covers TMS for patients diagnosed with treatment-resistant depression when other therapies haven’t worked.
Yes, if you’ve tried at least two antidepressants and psychotherapy without success, Medicare can approve coverage.
Without coverage, TMS therapy can cost between $9,000 and $15,000 for a full course.
Currently, Medicare covers TMS primarily for depression, not anxiety alone.
Yes. Your psychiatrist must submit documentation proving medical necessity before treatment begins.
Medicare Part B covers TMS as an outpatient mental health service.
Ask your doctor for a referral or search for Medicare TMS coverage providers in your area who specialize in depression treatment.
