Does Aetna cover TMS? The short answer is yes – but it depends on your specific plan and meeting certain clinical criteria. We’ll dive into the details below, expanding on what TMS entails, how it works, and exactly what you’ll need to qualify for coverage.
Understanding TMS and Its Uses
What is TMS?
Transcranial Magnetic Stimulation (TMS) is an FDA-approved, non-invasive therapy primarily used for major depressive disorder (MDD), treatment-resistant depression (TRD),and obsessive-compulsive disorder (OCD) . TMS utilizes magnetic pulses delivered through a coil placed on the scalp, stimulating specific regions of the brain associated with mood regulation.
Originally approved by the FDA in 2008 for adults suffering from major depressive disorder who haven’t adequately responded to antidepressant medications, TMS has increasingly become a trusted option in mental health treatment, providing hope to those who have struggled to find relief elsewhere.
How Does TMS Work?
TMS therapy works by using brief magnetic pulses to generate electric currents in targeted areas of the brain, notably the dorsolateral prefrontal cortex, which is often underactive in people with depression. This stimulation helps restore proper brain function and connectivity, promoting symptom relief.
Unlike antidepressant medications, which can take weeks to be effective, TMS therapy typically shows noticeable results within 4-6 weeks, with some patients experiencing improvement even earlier.
TMS sessions are performed in outpatient clinics, usually lasting about 20 to 40 minutes each, administered five days per week for about six weeks. Prior to beginning TMS, a thorough psychiatric evaluation and medical history review ensure it’s the appropriate treatment option for the patient.
Does Aetna Cover TMS?
Navigating insurance for mental health treatments like TMS can be complex. If you’re asking, “Does Aetna cover TMS?”, the answer is typically yes – most plans will cover it once medical necessity is demonstrated and authorization is obtained.
Criteria for Coverage
Aetna generally requires:
- Diagnosis of MDD, confirmed by a treating psychiatric provider.
- Treatment Failures: Inadequate response to at least two separate antidepressant medication trials in the last five years at therapeutic doses or failure of an evidence-based psychotherapy course.
- Provider Certification: TMS must be administered in an in-network Aetna facility by a provider trained on an FDA-cleared TMS system.
How to Get Approved for TMS Treatment
- Clinical Documentation: Your psychiatrist compiles a history of past treatments, standardized depression scores (e.g., PHQ-9), and a formal recommendation for TMS.
- Prior Authorization Request: Your Provider will submit the treatment plan and all supporting documentation via Aetna’s provider portal or fax to Aetna Utilization Management.
- Benefits Verification: Contact Aetna member services to confirm network status of your chosen TMS clinic and verify any session copays or coinsurance percentages.
- Schedule Treatments: Upon approval, book your initial block of daily sessions, keeping track of any session limits or renewal requirements specified in your authorization letter.
Be sure to follow all of the above steps, as doing so will increase your chances of obtaining approval for TMS treatment under Aetna.
Comparing Coverage: Aetna, Medicare, BCBS and Other Providers
When it comes to covering TMS and other esketamine treatments, the landscape can vary slightly between Aetna, Medicare, Blue Cross Blue Shield (BCBS) and other providers. Each has its own criteria and processes for approval, which can affect accessibility for patients with treatment-resistant depression or major depressive disorder.
Aetna Coverage Details
Aetna generally approves TMS when a psychiatric provider confirms MDD, there’s documented failure of at least two antidepressant trials (or evidence‑based psychotherapy), and the treatment is performed in an Aetna‑certified facility using an FDA‑cleared system.
Medicaid and Medicare Coverage
Medicaid coverage for TMS is state-dependent, often requiring extensive documentation of diagnosis, previous treatment attempts, and pre-authorization. Each state’s Medicaid program has unique criteria, so reviewing your local guidelines is crucial.
Medicare Part B covers TMS therapy for adults diagnosed with treatment-resistant depression, requiring thorough documentation, including a record of failed medication trials. Medicare typically authorizes a set number of initial treatments, and further authorization requires demonstrating positive patient response.
Blue Cross Blue Shield Coverage
Blue Cross Blue Shield coverage for TMS therapy generally requires a confirmed diagnosis of treatment-resistant depression, documented treatment attempts, and prior authorization. Coverage specifics and ease of approval can vary between states and specific BCBS plans. For example, BCBS in states like New York or Utah may have clearer guidelines compared to others, where more stringent documentation might be required.
Other Insurance Providers
- SelectHealth: Requires a confirmed MDD diagnosis, documentation of four failed antidepressant trials, and requires FDA‑cleared device use in‑network.
EMI Health: Requires prior authorization for high-cost procedures; TMS, once approved, is covered under the plan’s medical benefits and subject to in-network cost-sharing per member’s specific plan.
Cigna: Requires a confirmed MDD diagnosis, unsuccessful prior treatments, and TMS must be administered in certified healthcare facilities following approved protocols.
United Healthcare: Covers TMS following detailed diagnostic and treatment criteria, including documented trials of antidepressants, clinical assessment scores, and certification of the administering healthcare provider.
TRICARE: Covers outpatient rTMS for Major Depressive Disorder in adults 18 or older after failed less-intensive interventions; requires prior authorization under Tricare Prime, Select, and West plans.
University of Utah Health Plans: Currently does not cover any form of repetitive TMS for behavioral health, classifying it as investigational; MDD treatment may fall under behavioral health carve-outs in PMPM plans.
DMBA (Deseret Mutual Benefits Administration): Preauthorization required for specialized outpatient procedures; coverage levels vary by plan (e.g., PPO 90 pays 100% after $45 copay, HSA plans cover 60-80% after deductible).
Cost Considerations
While insurance generally covers a significant portion of TMS treatment, patient costs can vary widely based on specific insurance plans. It’s crucial to confirm the exact financial responsibility, including:
- Copays or coinsurance per session.
- Annual deductible amounts.
- Out-of-pocket maximums.
Always verify directly with your insurance representative to understand your specific financial obligations.
Conclusion – Why Choose Anew Therapy
Navigating insurance coverage for TMS therapy doesn’t have to be daunting. Understanding the essential criteria, insurance processes, and comparisons among providers can help streamline your approval and treatment experience.
At Anew Therapy Utah, we:
- Utilize FDA-cleared NeuroStar® TMS systems in a comfortable, welcoming environment
- Coordinate directly with SelectHealth and other insurers to handle prior authorizations
- Provide a dedicated team to guide you through treatment scheduling, insurance questions, and follow-up care
- Offer affordable financing through CareCredit, so cost is never a barrier to receiving the treatment you need
Ready to explore TMS? Visit our TMS services page to learn more, check your coverage, and schedule a consultation. Your journey to relief could begin within days – let Anew Therapy help you take that first step toward lasting wellness.
Searching for the best TMS clinic in Utah? Anew Therapy offers expert care and proven results. Schedule your free evaluation today.
