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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that repetitive transcranial magnetic stimulation (rTMS) is only considered medically necessary 
in adults who have a confirmed diagnosis of major depressive disorder (MDD), single or recurrent episode and 
meet the following criteria: 
 
1. Resistance to treatment as evidenced by a lack of a clinically significant response to four (4) trials of 
psychopharmacologic agents in the current depressive episode; 
 
-Two different agent classes, at or above the minimum effective dose and duration and includes trials of at least 
two (2) evidence-based augmentation therapies; or 
 
2. Inability to tolerate psychopharmacologic agents as evidenced by four (4) trials of psychopharmacologic 
agents with distinct side effects; or  
3. History of response to rTMS in a previous depressive episode; or 
4. History of response to electroconvulsive therapy (ECT) in a previous or current MDD episode, or inability to 
tolerate ECT, and rTMS is considered a less invasive treatment option; and 
5. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate 
frequency and duration without significant improvement in depressive symptoms as documented by 
standardized rating scales that reliably measure depressive symptoms; and 
6. The rTMS treatment is delivered by a device that is FDA-approved or ?cleared for the treatment of MDD in 
a safe and effective manner. rTMS treatment should generally follow the protocol and parameters specified in 
the manufacturer?s user manual, with modifications only as supported by the published scientific evidence 
base; and  
7. The order for treatment (or retreatment) is written by a physician (MD or DO) who has examined the patient 
and reviewed the record. The physician must have experience in administering rTMS therapy and the treatment 
must be given under direct supervision of this physician, i.e., he or she must be in the area and be immediately 
available. 
 
You can find this rule in Local Coverage Determination (LCD):Transcranial Magnetic Stimulation (L33398) - 
Effective October 1, 2020. 
 
The rules say that the benefits of TMS use must be carefully considered against the risk of potential side effect 
in patients with any of the following: 
 
-Seizure disorder or any history of seizure (except those induced by ECT or isolated febrile seizures in infancy 
or childhood without subsequent treatment or recurrence). Additional consideration should be given for 
individuals on medications which may lower the seizure threshold or with conditions rendering the patient 
more prone to seizures, such as alcoholism; 
-Presence of vagus nerve stimulators leads in the carotid sheath; 
-Presence of an implanted medical device located less than 30 cm from the TMS magnetic coil, including but 
not limited to pacemakers, implanted defibrillators, or vagus nerve simulators. 
 
You can find this rule in Local Coverage Determination (LCD):Transcranial Magnetic Stimulation (L33398) - 
Effective October 1, 2020. 
 
The rules say that TMS is not considered reasonable and necessary for any of the following: 
 
-Presence of psychotic symptoms in the current depressive episode; 
-Acute or chronic psychotic disorder such as schizophrenia, schizophreniform disorder, or schizoaffective 
disorder, or any other neuropsychiatric disorder; 
-Neurologic conditions that include epilepsy, cerebrovascular disease, dementia, increased intracranial 
pressure, having a history of repetitive or severe head trauma, or with primary or secondary tumors in the 
central nervous system; 
-Persons with conductive, ferromagnetic or other magnetic-sensitive metals implanted in their head which are 
non-removable and within 30 cm of the TMS magnetic coil. Examples include cochlear implants, implanted 
electrodes/stimulators, aneurysm clips or coils stents, and bullet fragments. (Dental amalgam fillings are not 
affected by the magnetic field and are acceptable for use with TMS.) 
-Maintenance therapy is not currently supported by evidence from clinical trials and therefore, is considered 
not reasonable and necessary. 
-All other conditions not included in the above list of ?Indications.? 
 
You can find this rule in Local Coverage Determination (LCD):Transcranial Magnetic Stimulation (L33398) - 
Effective October 1, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. [e.g. The 
Plan contract also says that acupuncture services are not covered by the Plan. You can find this information on 
page 27 of the Plan's 2010 Evidence of Coverage.]