Does United Healthcare 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 United Healthcare Cover TMS?
Navigating insurance for mental health treatments like TMS can be complex. If you’re asking, “Does United Healthcare cover TMS?”, the answer is typically yes – provided certain criteria is met.
Criteria for Coverage
UnitedHealthcare typically requires:
- DSM-5 MDD Diagnosis confirmed by a licensed psychiatrist.
- Failed Antidepressant Trials: Documentation of at least three adequate medication trials without satisfactory response.
- Baseline and Follow-Up Scales: Completion of depression rating scales (e.g., HAM-D, MADRS) at baseline and at regular intervals to demonstrate response.
- REMS Certification: The administering provider must be certified under the TMS system’s REMS protocol (where applicable).
How to Get Approved for TMS Treatment
- Comprehensive Evaluation: In-person assessment by a UnitedHealthcare-contracted psychiatrist to document diagnosis, prior treatments, and baseline scale scores.
- Prior Authorization Submission: Provider submits a detailed request, including clinical notes, scale results, and provider certification, to UnitedHealthcare’s Behavioral Health Utilization Management.
- Authorization Review: UnitedHealthcare reviews for medical necessity and may request additional information or peer-to-peer review.
- Coordination of Care: Once approved, confirm your TMS provider is in-network, then you can go ahead and schedule your TMS treatment course.
Be sure to follow all of the above steps, as doing so will increase your chances of obtaining approval for TMS treatment under United Healthcare.
Comparing Coverage: United Healthcare, Medicare, BCBS and Other Providers
When it comes to covering TMS and other esketamine treatments, the landscape can vary slightly between United Healthcare, 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.
UnitedHealthcare Coverage Details
UnitedHealthcare covers TMS for adults with treatment‑resistant depression, requiring: a DSM‑5 MDD diagnosis by a psychiatrist, documentation of three failed medication trials, baseline and follow‑up depression scale scores, and administration in a UHC‑contracted, certified clinic.
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
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.
SelectHealth: Requires a confirmed MDD diagnosis, documentation of four failed antidepressant trials, and requires FDA‑cleared device use in‑network.
Aetna: Provides coverage upon medical necessity verification, requiring proof of inadequate responses to previous treatments and ensuring TMS is conducted under proper medical supervision.
Cigna: Requires a confirmed MDD diagnosis, unsuccessful prior treatments, and TMS must be administered in certified healthcare facilities following approved protocols.
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 United Healthcare 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.
SSearching for the best TMS clinic in Utah? Anew Therapy offers expert care and proven results. Schedule your free evaluation today.
