Medicare & Medicaid Coverage FAQs

Quick summary (the short answers)

• Medicare: Often covers TMS for treatment-resistant major depressive disorder when the plan’s clinical criteria (such as prior medication trials) are met and prior authorization is approved. Inspire routinely helps patients with Medicare benefits checks and authorizations. 

• Medicaid: Coverage varies by state. Some state Medicaid plans cover TMS with strict medical necessity criteria; others do not. Inspire collects your insurance details and runs a state-specific benefits check. 

• Pre-authorization: Nearly always required. Insurers want documented prior treatment attempts, objective symptom measures (PHQ-9), and a psychiatrist’s letter of medical necessity. Inspire will run the authorization for you once you approve.
  

Does Medicare cover TMS?

• Typical Medicare approach: Medicare coverage policies commonly require documentation that the patient had a prior medication trial(s) or intolerance and that TMS is medically necessary for treatment-resistant major depressive disorder. The exact requirement can vary (some documents used by clinics note Medicare may require at least one failed antidepressant while commercial payers often require two). Always check your specific Medicare plan details.

• How Inspire helps: Inspire runs the Medicare benefits check, prepares the required documentation (treatment history, PHQ-9, letter of medical necessity) and submits prior-authorization requests on your behalf. If Medicare requires additional documentation we coordinate with your treating clinician. 
  

Does Medicaid cover TMS?

State variation:

Medicaid is administered by states, so coverage and rules differ. Some state Medicaid programs will pay for TMS for clearly documented, treatment-resistant depression; others exclude it or require extensive prior authorization and documentation. The clinic intake form explicitly lists Medicaid as a possible payer, and the clinic will verify coverage for your state plan.

What to expect:

Expect the same paperwork as other payers: documentation of prior medication trials, therapy history (if required), symptom measures and a psychiatrist’s treatment summary. If coverage is denied, Inspire can discuss alternatives (sliding scale, hardship assistance, or out-of-network options). 

What do insurers look for in a prior authorization?

Insurers typically request:

• History of prior treatments: Names/doses/dates of antidepressants tried and whether they were adequate trials (e.g., therapeutic dose/duration). Some payers require two failed antidepressants from different classes; others (e.g., Medicare) may have slightly different thresholds.

• Psychotherapy history, when required (notes showing a course of evidence-based psychotherapy).

• Objective symptom scores: PHQ-9 or similar measures demonstrating severity and tracking response. Inspire collects PHQ-9 during intake and uses it in screening.

• Provider documentation: A psychiatrist’s letter of medical necessity explaining why TMS is appropriate for your case.

Because prior authorization is the norm, plan ahead - the clinic will run the check and tell you what’s needed. 

How Inspire TMS Denver supports Medicare & Medicaid patients

Benefits checks:

Inspire runs payer-specific checks to confirm whether your plan covers TMS and what documentation is required. This includes Medicare, Tricare, and state Medicaid plans when applicable.

Prior authorization submission:

The clinic prepares the necessary clinical documents and submits authorizations for you, following the insurer's forms and requirements.

Hardship & sliding-scale options:

If coverage is denied (common for off-label or accelerated treatments), Inspire offers sliding-scale or hardship pricing and can discuss self-pay packages.

What happens if coverage is denied

Appeals & next steps

Ask why:

The insurer must tell you the reason and which criterion was not met.

Request peer-to-peer review:

Your provider can request a clinician-to-clinician discussion with the insurer’s medical director.

Submit additional documentation:

Provide more detailed notes, symptom scores or a second psychiatric opinion if needed.

Consider alternatives:

If denied for off-label or accelerated care, discuss sliding-scale self-pay, hardship discounts, or an out-of-network option. Inspire documents that they offer discounted care for hardship and can work with patients when authorizations are denied. 

Timelines & practical tips

• Authorization time: Allow several business days (sometimes longer) for a prior authorization. Inspire runs benefits checks early so you receive an itemized estimate and a timeline before mapping/treatment scheduling.



• Gather records early: Collect medication lists, psychotherapy notes, PHQ-9/other symptom scores, and any prior TMS mapping or treatment notes. The faster you supply records, the quicker the authorization proceeds.