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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 transcranial magnetic stimulation (TMS) is a noninvasive method of brain stimulation. The 
technique involves placement of a small coil over the scalp and passing a rapidly alternating current through 
the coil wire which produces a magnetic field that passes unimpeded through the brain. Depending on 
stimulation parameters (frequency, intensity, pulse duration, stimulation site), repetitive TMS (rTMS) to 
specific cortical regions can either increase or decrease the excitability of the affected brain 
structures. The procedure is usually carried out in an outpatient setting and does not require anesthesia or 
analgesia. Transcranial magnetic stimulation has been investigated in the treatment of various disorders, 
primarily depression. In 2008 the U.S. Food and Drug Administration (FDA) granted 510(k) marketing 
clearance as a de novo device (assessed as low risk, no predicate device) for NeuroStar TMS to be utilized 
as a Class II rTMS device for the treatment of major depressive disorder in patients who had not responded to 
one adequate trial of antidepressant medication. 
 
The FDA first allowed marketing of deep transcranial magnetic stimulation (d-TMS) for the treatment of 
obsessive-compulsive disorder in August 2018. [FDA.gov (dTMS)] Deep transcranial magnetic stimulation (d-
TMS) uses magnetic pulses to target specific areas of the brain that have been implicated in certain conditions. 
 
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: 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 
Inability to tolerate psychopharmacologic agents as evidenced by four (4) trials of psychopharmacologic agents 
with distinct side effects; or History of response to rTMS in a previous depressive episode; or 
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 
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 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 
manufacturers user manual, with modifications only as supported by the published scientific evidence base; 
and 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 the Local Coverage Determination (LCD) Transcranial Magnetic 
Stimulation L33398. 
 
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.