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Decision: unknown

 
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: 
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).  
Coverage Limitations 
The benefits of TMS use must be carefully considered against the risk of potential side effects in patients with 
any of the following:  
 Seizure disorder or any history of seizures (except those induced by ECT or isolated febrile seizures in 
infancy without subsequent treatment or recurrence); 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. (Dental amalgam fillings are not affected by the magnetic field and are 
acceptable for use with TMS). 
All other uses of Transcranial Magnetic Stimulation are considered experimental or investigational and are not 
allowed reimbursement per Statute XVIII, 1862 (a) (1)(D) & (E).   
Retreatment 
 
Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently 
developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a 
greater than 50% improvement in standard rating scale measurements for depressive symptoms. All other uses 
of TMS therapy are considered investigational or experimental and remain non-covered services. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L37088: Transcranial Magnetic 
Stimulation (TMS). 
 
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.