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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 state that left Prefrontal rTMS of the brain is considered medically necessary for use in an adult who 
meets all four of the following criteria: 
 
1. Has a confirmed diagnosis of severe major depressive disorder (MDD) single or recurrent episode; and 
 
2. One or more of the following: 
 Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically 
significant response to a single trial of psychopharmacologic agents in the current depressive episode; 
or 
 Inability to tolerate psychopharmacologic agents as evidenced by two trials of psychopharmacologic 
agents from two different agent classes; or 
 History of response to rTMS in a previous depressive episode; or 
 A history of response to ECT in a previous or current episode or an inability to tolerate ECT, or is a 
candidate for, but has declined ECT and rTMS is considered a less invasive treatment option. 
Resistance to treatment is defined by a failure to achieve a 50% reduction in depressive symptoms, in 
accordance with objective measures such as Geriatric Depression Scale (GDS), the Personal Health 
Questionnaire Depression Scale (PHQ-9), the Beck Depression Inventory (BDI), the Montgomery Asberg 
Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS), the 
Inventory for Depressive Symptomatology Systems Review (IDS-SR) or Hamilton Rating Scale for Depression 
(HAM-D), from a pharmacologic trial where the medication is administered at both an adequate dose and for 
an adequate period of time consistent with accepted standards of care. 
 
Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently 
developed relapse of depressive symptoms as evidenced by a 50% worsening in the prior best response using 
the same rating scale (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR scores). 
 
Patients must have responded to prior treatments as evidenced by a greater than 50% improvement in standard 
rating scale measurements for depressive symptoms. (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS or 
IDS-SR scores). Coverage Limitations 
 
TMS therapy not ordered by a psychiatrist who has experience administering TMS therapy and furnished under 
direct supervision, by a qualified physician (MD or DO), will be considered not medically reasonable and 
necessary and not subject to coverage. 
 
The treatment must be provided by use of a device approved by the FDA for the purpose of supplying 
Transcranial Magnetic Stimulation. 
 
The benefits of TMS use must be carefully considered against the risk of potential side effects in patients. The 
use of TMS in patients with any of the following may be considered not medically reasonable and necessary 
will not be covered: 
 
Seizure disorder or any history of seizures (except those induced by ECT or isolated febrile seizures in infancy 
without subsequent treatment or recurrence) or any condition or treatment that may lower the seizure threshold; 
or  presence of acute or chronic psychotic symptoms or disorders (such as schizophrenia, schizophreniform or 
schizoaffective disorder) in the current depressive episode; or neurological conditions that include epilepsy, 
cerebrovascular disease, dementia, increased intracranial pressure, history of repetitive or severe head trauma, 
or primary or secondary tumors in the central nervous system, or 
 
Presence of an implanted magnetic-sensitive medical device located less than or equal to 30 cm from the TMS 
magnetic coil or other implanted metal items including, but not limited to a cochlear implant, implanted cardiac 
defibrillator (ICD), pacemaker, Vagus nerve stimulator (VNS), or metal aneurysm clips or coils, staples or 
stents. 
 
All other uses of Transcranial Magnetic Stimulation, including "maintenance therapy", continuous therapy, 
rescue therapy and extended active therapy are considered investigational and experimental as they are not 
supported by controlled clinical trials and they are considered not reasonable and necessary. This non-coverage 
is extended to any other terminology that may be given to a treatment episode that does not meet the defined 
requirements noted and defined as initial treatment or retreatment.   
 
Retreatment that occurs in close temporal proximity to a previous episode of treatment may be considered 
maintenance therapy or continuous therapy and not reasonable and necessary. It is expected that the time 
between treatment episodes should allow for assessment, both clinically and by one or more standard rating 
scales, to clearly document that the patient responded and then relapsed. The number of retreatments is not 
limited at this time. However, frequent reporting of services may trigger focused medical reviews. 
 
All other uses of TMS therapy are investigational and/or experimental and are not covered. 
 
Routine performance of motor threshold re-determination during rTMS therapy will be considered not 
reasonable and necessary. More than three motor threshold redeterminations in a rolling six-month period will 
be denied.  Denied claims may be appealed with supporting documentation addressing the medical necessity 
(e.g. when there is a change in clinical status or medical regimen that is expected to alter cortical excitability). 
 
You can find this rule at the Medicare Local Coverage Determination (LCD)- L37088, Repetitive Transcranial 
Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder. 
 
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.