This is usually one of the first questions we get by phone and email at Southern California TMS Center. Although we have had only one patient receive 100% approval as of today, we are appealing coverage on a regular basis. Additionally the Federal Blue Shield/Blue Cross plan also know as the Federal Employee Health Benefits (FEHB) is one policy that covers TMS with prior authorization.
Unfortunately many people do not pursue TMS when they learn that TMS is not uniformly written into their policy. We have many potential patients tell us they are not interested in coming in for a consult because they have called their insurance and “TMS is not covered.” Additionally many Psychiatrists will not refer patients for TMS because it is not uniformly covered by insurance and the presumed out of pocket expenses the patient may face.
In my opinion there are several negative consequences to not coming in for a clinical consultation and automatically not considering TMS because of insurance coverage.
First, if the patient does not get a clinical consult we will not ever know if TMS is an appropriate treatment for the patient or how the patient might benefit from TMS versus other approved treatments for depression. Not all depression treatments work at each stage of depression although many clinicians apply treatments haphazardly without considering the amount of treatment resistance that is present with the individual.
Second, when patients don’t come in for a consultation we are not able to conduct a true benefits investigation. On a mass level this is unfortunate because the insurance industry may underestimate the true need for TMS. On an individual level the patient may have benefits that they are not aware of.
During the consultation we gather clinical and personal information about the patient to determine if TMS is an appropriate treatment. With this information we contact the insurance company to determine benefits given the unique clinical circumstances of the patient. In some cases we have been able to secure coverage with specific clinical indications.
If we are not able to get authorization quickly we then enter an appeal process with the insurance provider. When we enter the appeal process with an insurance company we formally join the many individuals who are communicating to the insurance industry that they want this treatment made more widely available. Large insurance companies do not adopt new treatments based on science and FDA approval. Insurance looks at wide spread demand from patients and clinicians. So does insurance cover TMS? The best way to find out and to change this to a uniform answer of “yes” is to get a consultation and to initiate a formal benefits investigation.
Although TMS has yet to be widely adopted by the major insurance companies, we are seeing some insurance companies pay for TMS.