Patient is 18 years of age or older.

Patient has a current diagnosis of Major Depressive Disorder and the severity is at least moderate to severe based on a standardized rating scale (such as the PHQ-9)

The current episode of depression must have some level of treatment resistance. This typically involves a range of antidepressant failure from as little as one up to as many as four failed medications. The medication trials must be of adequate duration and dose and have resulted in less than 50% improvement based on a standard rating scale. Medication intolerance can also count in place of failure. 

A documented previous course of failure to psychotherapy of sufficient time and frequency is also required.

Prior treatment response to TMS of at least 50% improvement in symptoms can authorize repeat coverage. Maintenance treatment is NOT covered, but retreatment with sufficient time having passed since the last TMS therapy course will be covered.

If a patient is a candidate for ECT, but cannot pursue or declines ECT treatment (or has a history of intolerance/side effects to ECT), TMS will typically be covered.

There are a few exclusion criteria - The patient cannot have ferromagnetic material near the brain/treatment site or medical devices in the body that may respond to magnetic fields. The patient should also not have active psychosis (or a psychotic disorder diagnosis), current suicide intent or action, active abuse of alcohol or drugs, or be pregnant or nursing. The patient must also not have a seizure disorder or other condition that places them at high risk for seizure.

Aetna - Requires failure to TWO previous antidepressants from TWO DIFFERENT medication classes. They also require failure to an AUGMENTATION strategy of some sort (combination of two different medications). The same criteria applies to intolerance to medications.

Anthem BCBS - Requires failure to TWO previous antidepressants from TWO DIFFERENT medication classes. They alternatively require INTOLERANCE TO FOUR medications with documented side effects. 

Beacon Health Options - Requires failure to TWO previous antidepressants from TWO DIFFERENT medication classes. They alternatively require INTOLERANCE TO FOUR medications with documented side effects. 

Cigna - Requires failure to TWO previous antidepressants from TWO DIFFERENT medication classes. They alternatively require INTOLERANCE TO FOUR medications with documented side effects. 

Humana - Requires failure to FOUR previous antidepressants from TWO DIFFERENT medication classes. The same criteria applies to intolerance to medications. Humana’s most recent policy also indicates they do not cover Theta Burst treatment despite FDA clearance for this in 2018 and studies showing equivalency to the standard 18.5 minute 10 Hz protocol.

Kaiser Permanente - Requires failure to TWO previous antidepressants from TWO DIFFERENT medication classes. They alternatively require INTOLERANCE TO FOUR medications with documented side effects. 

Medicaid - TMS is not currently covered in CO.

Medicare - Requires failure to a SINGLE previous antidepressant or intolerance to TWO antidepressants from separate classes.

Tricare West - TMS is a covered benefit for major depression when: “it is medically necessary and the patient failed to respond to a less intensive form of treatment, or a less intensive intervention is not appropriate.” This can be ONE TO TWO previous antidepressant failures or INTOLERANCE TO TWO medications from separate classes.

Optum/United Behavioral Health - Requires failure to FOUR previous antidepressants from TWO DIFFERENT medication classes. The same criteria applies to intolerance to medications.  Optum’s most recent policy also indicates they do not cover Theta Burst treatment despite FDA clearance for this in 2018 and studies showing equivalency to the standard 18.5 minute 10 Hz protocol.