Could your Insurance Carrier Pay or Reimburse for TMS Treatment?
We know that TMS is an exciting treatment possibility for millions of people who deal with severe chronic, overwhelming, and exhausting depression, day in and day out. But many of them just cannot afford to pay for it out of pocket…
Does insurance generally cover TMS treatment?
I try to be careful to avoid making any blanket statements about TMS insurance coverage. With any given patient, we must consider so many variables that generalizations just aren’t accurate, and I definitely don’t want to mislead anyone or give false hope. However, we can discuss the good news – that in the last few years, major national insurance carriers have increasingly written policies for coverage of TMS treatment – for patients who qualify. And I can describe the general coverage trends that I see at this time. While there are several different devices on the market for TMS treatment, NeuroStar is the brand name of the TMS equipment made by Neuronetics, the medical device company that brought the first TMS device through FDA clearance in 2008. According to NeuroStar.com, over 230 million patients have insurance policies that cover NeuroStar TMS Therapy through their individual health plans. That number has more than doubled in the last few years. It appears that most major national carriers now cover TMS under certain terms and conditions. However, each carrier’s ‘authorization’ criteria can and do vary from other carriers. And authorization depends upon several factors that are unique to the individual patient’s status. (Photo Credit: http://neurostar.com/en/how-neurostar-works/)
What ‘Authorization Criteria’ do insurance carriers look for?
Insurance companies look for a typical range of criteria in order to authorize TMS treatment. Physicians must give the patient a qualifying medical diagnosis (the treatment is “Medically Necessary”), and they must provide a prescription for TMS Treatment. Currently Major Depressive Disorder is the only FDA cleared indication.
Typical ‘Qualifying Criteria’ include the following – alone or in some combination:
- Failure to respond to pharmacologic antidepressant treatments
- additional augmentation strategies, and
- at least some form of psychotherapy – for example; cognitive behavioral therapy.
Can you estimate how many people have TMS coverage through their insurance plan?
Neuronetics is very active in advocating for all types of coverage and reimbursement of TMS treatment. For more information, their Patient’s Guide to Reimbursement Brochure is available online. At the date of this writing, NeuroStar offers a list of carriers that cover TMS treatment, as excerpted directly from the NeuroStar website:
“Below is a list of the insurance companies and applicable States that cover TMS Therapy if a patient meets the medical necessary requirements and all other necessary guidelines are met. Not all medical coverage policies or Behavioral Health Carve-Out Plan’s Treatment Guidelines for TMS Therapy can be listed.”
Anthem Blue Cross and Blue Shield
Blue Cross Blue Shield of Alabama
Blue Cross Blue Shield of Arizona
Blue Cross Blue Shield of Florida
Blue Cross Blue Shield of Hawaii (HMSA – Hawaii Medical Services Association)
Blue Cross Blue Shield of Kansas
Blue Cross Blue Shield of Louisiana
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Michigan and Blue Care Network of Michigan
Blue Cross Blue Shield of Minnesota
Blue Cross Blue Shield of Nebraska
Blue Cross Blue Shield of Rhode Island
Blue Cross Blue Shield of Tennessee
Blue Cross Blue Shield of Vermont
Blue Cross Blue Shield of Western New York (Under Health Now)
Blue Cross Blue Shield Federal Employee Program
Blue Cross of Idaho
Blue Shield of California
Blue Shield of Northeastern New York (Under Health Now)
Community Care of Oklahoma
Health Care Service Corporation (HCSC) for BCBS of Illinois, Montana, New Mexico, Oklahoma, and Texas
Health New England
Horizon Blue Cross Blue Shield of New Jersey
Independence Blue Cross
Optima Behavioral Health
Oxford Health Plans
Premera Blue Cross
Tufts Health Plan
United Healthcare/OPTUM by United Behavioral Health
MEDICARE PLANS (coverage is not consistent nationally because Medicare benefits are planned and administered regionally.)
First Coast Service Options, Inc.
NGS (National Government Services)
Medicaid of Vermont
NeuroStar.com offers additional details for each carrier (above) that is listed on the Neurostar website. To access these details, click on this link: https://neurostar.com/neurostar-health-insurance-coverage/, then click on the underlined insurance carrier you wish to know more about.
What about other types of coverage?
On a national basis, the Veterans Administration (VA) and Department of Defense (DOD) provide TMS treatment in some cases. Check with your local or area office for more information.
Does anyone work to make TMS coverage more available and more consistent?
The Clinical TMS Society was organized several years ago and has put much effort into working with insurance companies to develop appropriate coverage.
According to Psychiatrist Dr. Max Okasha, current Medical Director of Comprehensive Psychiatric Care, a private practice, and Associate Clinical Professor at Yale University; “The problem that we are facing is the lack of standardization between insurance companies and their coverage policies.”
Dr. Okasha offers his time and talents to bridge this gap for TMS treatment and payment coverage. He serves on the Board of Directors and serves as Co-Chair, along with Dr. Kevin Kinback, of the Insurance Committee of the Clinical TMS Society. Organized as a 501 (c)(6) “Trade Association”, not a charitable or scientific organization, its mission is to be a “professional association dedicated to optimizing clinical practice, awareness, and affordability of Transcranial Magnetic Stimulation therapy.”
Many of us in private practice continue our efforts to establish coverage and to make coverage appropriate. We are learning more about how TMS works and how to optimize the treatment for patients and insurance companies seem to have difficulty adapting to our clinical experience. This continues to be a struggle.
Dr. West’s Conclusion
Overall, the trend is very positive. Coverage policies are increasing and efforts are successful in gaining the attention of consumers, providers, and payers. But it is also important to remember that at this point in time, TMS authorization for coverage clearly depends on each carrier’s definition of ‘qualifying’, each patient’s medical history, medical necessity, determination of reasonable and necessary; and their physician’s diagnoses for authorization.
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