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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 for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare
Program Integrity Manual Chapter 3 Section 3.3.2.1.
The rules say all documentation must be maintained in the patient's medical record and available to the
contractor upon request. The medical record documentation must support the medical necessity of the services
as directed in this policy.
The attending physician must monitor and document the patient's clinical progress during treatment. The
attending physician must use evidence-based validated depression monitoring scales such as the Geriatric
Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression
Inventory (BDI), Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating
Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive
Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission
of symptoms.
You can find this rule in the Local Coverage Article: Billing and Coding: Transcranial Magnetic Stimulation
(TMS) (A57598) effective November 1, 2019.
The rules say TMS may be covered if prescribed and administered by a licensed physician who is
knowledgeable in the use of repetitive transcranial magnetic stimulation. Outpatient rTMS may be indicated for
patients with DSM-IV defined Major Depressive Disorder who have failed to benefit from initial treatment of
their depression.
Initial Treatment
Left Prefrontal rTMS of the brain is considered medically necessary for use in an adult who has a confirmed
diagnosis of severe major depressive disorder (MDD) single or recurrent episode; and
One or more of the following:
- Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically
significant response to one trial of psychopharmacologic agents in the current depressive episode from
at least two different agent classes. Each agent in the treatment trial must have been administered at an
adequate course of mono- or poly-drug therapy; or
- Inability to tolerate psychopharmacologic agents as evidenced by two trials of psychopharmacologic
agents from at least two different agent classes, with distinct side effects; or
- History of response to rTMS in a previous depressive episode; or
- If patient is currently receiving electro-convulsive therapy, rTMS may be considered reasonable and
necessary as a less invasive treatment option.
AND
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
The order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the patient
and reviewed the record. The physician will have experience in administering TMS therapy. The treatment
shall be given under direct supervision of this physician (physician present in the area but does not necessarily
personally provide the treatment).
You can find this rule in the Local Coverage Determination (LCD): Transcranial Magnetic Stimulation (TMS)
(L34641) effective November 1, 2019.
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.