Insurance

Because it is a relatively new procedure, TMS Therapy coverage varies between insurance providers. That’s why it is important that patients considering TMS Therapy contact their insurance provider before even starting the initial assessment so they can discuss their coverage.

The FDA approved TMS Therapy in 2008 for the treatment of Major Depressive Disorder under specific circumstances. Approval by the FDA is necessary in starting the process of enacting insurance coverage policies. However, this process is notoriously slow and complex and takes some time. Right now, insurance reimbursement for TMS Therapy is usually limited to those cases that meet the specific clinical criteria approved by the FDA, specifically its use in treating severe depression after medication has failed to yield satisfactory results.

We discuss insurance and payment issues more in depth below.

Insurance Coverage
Insurance policies and benefits for TMS Therapy vary greatly between health insurance plans. Some companies provide full reimbursement for TMS Therapy, while most offer only partial reimbursement. In most cases insurance companies do not list TMS Therapy as a regular benefit. However, it is possible to appeal these decisions to your insurance provider. Many patients who have appealed to their insurance provider have been able to obtain at least some coverage for their TMS Therapy. Either way, insurance companies usually determine eligibility for TMS Therapy on an individual basis and it is not guaranteed how insurance providers will decide your case.

The main blockade to insurance coverage is the hard fact that it takes time for health insurance plans to establish coverage policies for newly approved technologies. TMS Therapy was approved by the FDA in 2008 and as such may still not be recognized under all health insurance plans. However, it is important to note that due to recent healthcare advances, most major carriers and many small carriers now offer at least partial coverage for TMS Therapy.

It is highly recommended that patients work directly with their insurance companies to determine coverage for TMS Therapy. Contact your insurance company before your first visit to see if TMS Therapy is a covered benefit. Many insurance providers have pre-certification requirements for TMS Therapy and reimbursement can be delayed. So for instance, while the initial assessment for TMS Therapy is typically covered by insurance plans, the patient may be on the hook for full payment until reimbursement is received from their provider. Worse still, the patient may be liable for full payment if TMS Therapy isn’t covered at all.
Insurance Help
Health insurance is notoriously difficult to navigate. The responsibility for proper understanding of insurance coverage falls on you the patient. However, you are not alone. Most offices, clinics, and hospitals should be able to help you understand your benefits, file claims, and receive reimbursement. In an effort to help you negotiate reimbursement with your insurance company, your TMS prescribing psychiatrist or doctor should be willing to provide copies of your initial evaluation as well as ongoing clinical assessments which you can mail along with the insurance claim.

TMS prescribing psychiatrists and doctors understand that there are limitations to insurance coverage. If you feel that insurance coverage may be an issue, it is important to use a TMS prescribing psychiatrist or doctor who is able to discuss and help you with the complex process of insurance benefits and reimbursement. You will also want to choose a TMS prescribing psychiatrist or doctor who is able to help you in securing coverage, including writing letters on your behalf to argue for coverage.

Your doctor may also be able to help you with these items:
- Collect patient insurance information prior to your appointment.
- Provide patients with claim information.
- File the claim with your insurance company.
- Inform patients of their TMS benefits.
- Manage the process for reimbursement
If your insurance provider is not presently covering TMS Therapy and you would like assistance in securing coverage, the manufacturer of the TMS machine, Neuronetics, has developed the NeuroStar Reimbursement Support program, whose number is 1-877-622-2867. Reimbursement Support can check on your benefits and help you negotiate with your insurance provider for reimbursement, which is determined on a case-by-case basis.

Your insurance carrier may ask you for the TMS CPT codes: the motor threshold CPT Code is 90867, the TMS treatment code is 90868, and the reassessment of the motor threshold code is 90869.

TMS device manufacturer Neuronetics has started the NeuroStar Reimbursement Support (NRS). This program is committed to helping TMS patients who are using the NeuroStar obtain insurance coverage for their treatment by working with physician advocates and insurance companies. To learn more, visit NeuroStar Reimbursement Support (NRS)

This list is of providers who currently offer coverage for TMS Therapy. This information is for your consideration only and TMS+YOU cannot verify the current status or accuracy of the information presented. If you do not see your carrier in this list it may be for multiple reasons, including they do not cover TMS Therapy or just started carrying it. In any event, it is your responsibility and the responsibility of your doctor to obtain and verify all information regarding your insurance and any medical procedure.

Commercial Plans

Following is a list of the insurance companies and applicable states that cover TMS if a patient meets the necessary requirements:

Aetna

Covers Various States

Policy Number: #0469

Aetna Website

Anthem Blue Cross and Blue Shield

Covers California, Georgia, Nevada, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Ohio, Virginia, Wisconsin, New York

Policy Number: #BEH.00002

Anthem Blue Cross and Blue Shield Website

Arkansas Blue Cross Blue Shield

Covers Arkansas

Policy Number: #2003055

Arkansas Blue Cross Blue Shield Website

Blue Cross Blue Shield of Alabama

Covers Alabama

Policy Number: #170

Blue Cross Blue Shield of Alabama Website

Blue Cross Blue Shield of Arizona

Covers Arizona

Policy Number: #N/A

Blue Cross Blue Shield of Arizona Website

Blue Cross Blue Shield of Florida

Covers Florida

Policy Number: #01-93875-18

Blue Cross Blue Shield of Florida Website

Blue Cross Blue Shield of Hawaii (HMSA – Hawaii Medical Services Association)

Covers the Hawaiian Islands

Policy Number: MM.12.015

Blue Cross Blue Shield of Hawaii Website

Blue Cross Blue Shield of Kansas

Covers Kansas

Policy Number: #N/A

Blue Cross Blue Shield of Kansas Website

Blue Cross Blue Shield of Louisiana

Covers Louisiana

Policy Number: #00121

Blue Cross Blue Shield of Louisiana Website

Blue Cross Blue Shield of Massachusetts

Covers Massachusetts

Policy Number: #297

Blue Cross Blue Shield of Massachusetts Website

Blue Cross Blue Shield of Michigan and Blue Care Network of Michigan

Covers Michigan

Policy Number: #N/A

Blue Cross Blue Shield of Michigan Website

Blue Cross Blue Shield of Minnesota

Covers Minnesota

Policy Number: #X-14

Blue Cross Blue Shield of Minnesota Website

Blue Cross Blue Shield of Mississippi

Covers Mississippi

Policy Number: A.2.01.50…

Blue Cross Blue Shield of Mississippi MAIN Website

Blue Cross Blue Shield of Nebraska

Covers Nebraska

Policy Number: #IV.67 (Within the Medical Policy Manual)

Blue Cross Blue Shield of Nebraska Website

Blue Cross Blue Shield of North Carolina

Covers North Carolina

Policy Number: #N/A

(Please Note: The TMS Therapy Medical Coverage Policy falls under the Magellan Behavioral Health Medical Necessity Criteria Guidelines. Please refer to TMS Treatment beginning on page 131.)
Magellan Behavioral Health Website

Blue Cross Blue Shield of Rhode Island

Covers Rhode Island, Massachusetts and New Hampshire

Policy Number: N/A

Blue Cross Blue Shield of Rhode Island Website

Blue Cross Blue Shield of Tennessee

Covers Tennessee

Policy Number: N/A

Blue Cross Blue Shield of Tennessee Website

Blue Cross Blue Shield of Vermont

Covers Vermont

Policy Number: N/A

Medical Coverage Policy Link: N/A

Blue Cross Blue Shield of Western New York (Under Health Now)

Covers Western New York

Policy Number: N/A

Blue Cross Blue Shield of Western New York Website

Blue Cross Blue Shield of Wyoming

Covers Wyoming

Policy Number: #2.01.50.0

Blue Cross Blue Shield of Wyoming Website

Blue Cross Blue Shield Federal Employee Program

Covers Federal Employees

Policy Number: #2.01.50

Blue Cross Blue Shield Federal Employee Program Website

Blue Cross of Idaho

Covers Idaho

Policy Number: #2.01.50

Blue Cross of Idaho Website

Blue Shield of California

Covers California

Policy Number: N/A

Blue Shield of California Website

Blue Shield of Northeastern New York (Under Health Now)

Covers Northeastern New York

Policy Number: N/A

Blue Shield of Northeastern New York Website

Capital Blue Cross

Covers Counties in Central Pennsylvania and Lehigh Valley

Policy Number: #N/A

Magellan Behavioral Health Website: (The TMS Therapy Medical Necessity Criteria Guidelines begin on page. 137)
Please Note: Typically for this insurance company’s plans, Magellan Behavioral Health is the Behavioral/Mental Health Carve-Out company and manages these benefits.

Cigna

Covers Various States

Policy Number: #0383

Cigna Website

Community Care of Oklahoma

Covers Oklahoma

Policy Number: #N/A

Community Care of Oklahoma Website

Emblem Health

Covers New York, Connecticut and New Jersey

Policy Number: # MG.MM.ME.43v3

Emblem Health Website

Excellus Blue Cross Blue Shield

Covers New York

Policy Number: 3.01.09…

Excellus Blue Cross Blue Shield Website

Harvard Pilgrim

Covers Massachusetts

Policy Number: #N/A

Harvard Pilgrim Website

Health Care Service Corporation (HCSC) for BCBS of Illinois, Montana, New Mexico, Oklahoma, and Texas

Policy Number: #PSY301.015

Please Note: If the Coverage Policy cannot be accessed directly, please continue with the following after being directed to the BCBS state’s website:
Step 1. Disclaimer Page: Read and click on “I Accept”
Step 2. Medical Policies Page: Click on Updated Policies
Step 3. Update Page: Click on PSY301.015 Repetitive Transcranial Magnetic Stimulation (rTMS)

Health Net

Covers California, Arizona, Washington, Oregon, Connecticut

Policy Number: #NMP 508

Health Net Website

Health New England

Covers Central and Western Massachusetts

Policy Number: N/A

Health New England Website

Highmark Blue Cross Blue Shield -- Delaware

Covers Delaware

Policy Number: Z-4-006…

Website

Highmark Blue Cross Blue Shield -- Pennsylvania

Covers Pennsylvania

Policy Number: Z-4-008…

Website

Horizon Blue Cross Blue Shield of New Jersey

Covers New Jersey

Policy Number: #104

Horizon Blue Cross Blue Shield of New Jersey Website

Highmark Blue Cross Blue Shield -- West Virginia

Covers West Virginia

Policy Number: Z-4-008…

Website

Independence Blue Cross

Covers Pennsylvania

Policy Number: #07.03.22

Independence Blue Cross Website

Independent Health Association

Covers Upstate New York

Policy Number: #M20130418035

Independent Health Association Website
Please Note: This link will only route you to the Policies Main Page. Only In Network Providers may access the medical coverage policy with this link and by using the provider’s log-in information (username and password). For all others, please contact Independent Health Association directly to obtain a copy of the medical coverage policy.

MVP Healthcare

Covers New Hampshire, New York, and Vermont

Policy Number: #7.102

MVP Healthcare

Optima Behavioral Health

Covers Maryland, North Carolina, Virginia, West Virginia, Washington D.C.

Policy Number: N/A

Please contact Optima Behavioral Health directly for a copy of the medical policy.

OPTUM by United Behavioral Health

Covers:Various States.
Policy Number:#BHCDG852014..

The link above is for Coverage Determination Guidelines for ommercial Plans (including Oxford Health Plans).

*Please Note: Typically, Behavioral Health services and plans are managed by OPTUM by United Behavioral Health, but each plan’s benefits and coverage for TMS Therapy may vary. It is highly recommended that the TMS provider conduct a Benefits Investigation in order to verify if benefits and coverage are available for TMS Therapy based upon the specific plan.
website

Oxford Health Plans

*Please Note: Oxford Health Plans is a product of United Healthcare. For further information regarding the Medical Coverage Policy, please also refer to United Healthcare/OPTUM by United Behavioral Health listed below.

Covers Various States

Policy Number: #BEHAVIORAL 025.7 T2

Oxford Health Plans Website

Preferred One

Covers Minnesota

Policy Number: MC/M025…

Preferred One Website

Premera Blue Cross

Covers Washington and Alaska

Policy Number: #2.01.526

Premera Blue Cross Website

Priority Health

Covers Michigan and Other States

Policy Number: #91563-R1

Priority Health Website

Public Employees Insurance Agency (PEIA)

*Please Note: Depending on the plan type, PEIA plans are managed by either Health Smart or The Health Plan. Please verify the plan detail by contacting the Customer Service Department on the back of the patient’s insurance card.

Covers Ohio and West Virginia

Health Smart
- Third Party Administrator (TPA) for the PEIA Self-Funded Plans
- Policy Number: N/A
- Please contact Health Smart directly for a copy of the TMS Coverage Guidelines.

The Health Plan
- Manages certain plans for the PEIA (i.e., Fully Funded Plans, HMO Plans)
- Policy Number: N/A
- Follows Medicare’s Local Coverage Determination and medical necessity. Please refer to Palmetto GBA’s (Medicare Administrative Contractor for West Virginia) Local Coverage Determination:LCD #L34869

The Regency Group

Regency Blue Cross Blue Shield
- Covers Oregon, Utah

Regency Blue Shield
- Covers Idaho, Washington

Policy Number: #148

The Regence Group Website

Highmark Blue Cross Blue Shield -- New Jersey

Covers New Jersey

Policy Number: #104..

MAIN COMPANY Website

Tufts Health Plan

Covers Massachusetts

Policy Number: #2113347

Tufts Health Plan Website

United Healthcare/OPTUM by United Behavioral Health

UNITED HEALTHCARE
- Covers Various States
- Policy Number: #2015T0536G
- United Healthcare Website

OPTUM by United Behavioral Health
- Covers Various States
- Policy Number: #BHCDG852014
- Coverage Determination Guidelines: OPTUM by United Behavioral Health Website

Univera

Covers New York

Policy Number: 3.01.09…

Univera Website

Government Plans

Most states have the same LCD#, but are listed separately by state.

Cahaba

Covers Alabama, Georgia and Tennessee

Local Coverage Determination (LCD) Number: #L32834

Cahaba #L32834 – Alabama

Cahaba #L32834 – Georgia

Cahaba #L32834 – Tennessee

CGS Administrators, LLC

Covers Kentucky and Ohio
Local Coverage Determination (LCD) Number: #L36469
CGS Administrators, LLC Website

First Coast Service Options, Inc.

Covers Florida, Puerto Rico, and Virgin Islands

Local Coverage Determination (LCD) Number: #L33676

First Coast #L33676 – Florida

First Coast #L33676 – Virgin Islands

Independence Blue Cross

Covers: PA
Policy Number:#MA07.035a…
website

Medicaid of Vermont

Covers: VT
Policy Number: N/A
website

NGS (National Government Services)

Jurisdiction K

Covers Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont

Local Coverage Determination (LCD) Number: #L32038

NGS #L32038 – Connecticut

NGS #L32038 – Maine

NGS #L32038 – Massachusetts

NGS #L32038 – New Hampshire

NGS #L32038 – New York

NGS #L32038 – Rhode Island

NGS #L32038 – Vermont

Jurisdiction 6/G

Covers Illinois, Minnesota, Wisconsin

Local Coverage Determination (LCD) Number: #L32038

NGS #L32038 – Illinois

NGS #L32038 – Minnesota

NGS #L32038 – Wisconsin

Noridian Healthcare Solutions, LLC

*Please Note: For the Noridian Jurisdictions listed below, the TMS CPT Codes and Procedure were originally on the general Non-Covered Services Local Coverage Determination (LCD). Effective 4/1/16, the TMS CPT Codes and Procedure were removed from the this list (Please refer to the Revision History Information towards the end of the LCD for the TMS CPT Codes Removal information).

Jurisdiction E
Covers Covers American Samoa, Guam, Hawaii, Northern Mariana Islands, California, Hawaii, Nevada
Local Coverage Determination (LCD) Number: #L36219
Noridian Healthcare Solutions, LLC Website

Jurisdiction F
Covers Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming
Local Coverage Determination (LCD) Number: #L36219
Noridian Healthcare Solutions, LLC Website

Novitas

Jurisdiction L

Covers District of Columbia, Delaware, Maryland, New Jersey and Pennsylvania

Local Coverage Determination (LCD) Number: #L32055

Novitas #L32055 – Delaware

Novitas #L32055 – District of Columbia

Novitas #L32055 – Maryland

Novitas #L32055 – New Jersey

Novitas #L32055 – Pennsylvania

Jurisdiction H

Covers Arkansas, Colorado, Louisiana, New Mexico, Oklahoma, Mississippi and Texas

Local Coverage Determination (LCD) Number: #L33660

Novitas #L33660 – Arkansas

Novitas #L33660 – Colorado

Novitas #L33660 – Louisiana

Novitas #L33660 – New Mexico

Novitas #L33660 – Mississippi

Novitas #L33660 – Oklahoma

Novitas #L33660 – Texas

OPTUM by United Behavioral Health

Covers: Various States.
Policy Number: #MA07.035a..

Link provides Coverage Determination Guidelines for Medicare Advantage Plans

Palmetto GBA

Covers North Carolina, South Carolina, Virginia, West Virginia

Local Coverage Determination (LCD) Number: #L34170

Palmetto #L34170 – North Carolina

Palmetto #L34170 – South Carolina

Palmetto #L34170 – Virginia

Palmetto #L34170 – West Virginia

Tricare

Covers: All States.
Policy Number:N/A..

Covers Various States. Tricare designates contractors for each region. Please refer to the region and links below for more information.

Tricare Website: Below are the various Tricare sections and links for covered services. The Tricare Policy with the medical necessity criteria for TMS Therapy is not available at this time. We will provide the necessary updates once more information becomes available.

WPS (Wisconsin Physicians Service Insurance Corporation)

Jurisdiction 5
Covers Iowa, Kansas, Missouri and Nebraska
Local Coverage Determination (LCD) Number: #L34641
WPS #L34641 – Iowa
WPS #L34641 – Kansas
WPS #L34641 – Missouri
WPS #L34641 – Nebraska

Jurisdiction 8
Covers Indiana and Michigan
Local Coverage Determination (LCD) Number: #L34641
WPS #L34641 – Indiana
WPS #L34641 – Michigan

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