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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 Noridian considers TMS therapy reasonable and necessary when it is furnished in 
accordance with the accepted standards of medical practice, when it is furnished in a setting appropriate to the 
patients medical needs and condition, when it meets but does not exceed the patients medical need and when 
it is ordered and furnished by qualified personnel.  It is expected that TMS therapy will be ordered by a 
psychiatrist and furnished under direct supervision of a qualified physician (MD or DO) who has experience 
administering TMS therapy. 
 
Initial Treatment 
 
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.  
A dose will be considered adequate when the medication is administered consistent with the FDA label. Where 
starting dosage is lower than maximum recommended dosage, the dose of any medication will be considered 
adequate when an initial response failure is followed by titrating the dosage upwards towards the maximum 
recommended dosage. Where such titration does not occur, the record must document the rationale for the 
decision not to increase the dose. 
 
Duration of therapy will be considered adequate, when a particular medication is administered for a length of 
time consistent with expectations for expected response times for that medication or class of medications as 
defined in the medical literature supporting the efficacy of that medication or medication class and by the 
standard of care. Psychopharmacologic agent side effects will be considered intolerable, when those side 
effects are of a nature where they are not expected to diminish or resolve with continued administration of the 
drug. 
 
AND 
 
3. 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 
 
4. The order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the 
patient and reviewed the record. The psychiatrist will have experience in administering TMS therapy. The 
treatment shall be given under direct supervision of a qualified physician (physician present in the area and 
immediately available but does not necessarily personally provide the treatment). 
 
NOTE: Please refer to the "Provider Qualification" section for qualified physician and direct supervision 
requirements. 
 
Therapeutic repetitive transcranial magnetic stimulation treatment; subsequent motor threshold re-
determination with delivery and management is considered reasonable and necessary when there is a change in 
clinical status or medical regimen that is expected to alter cortical excitability.  The medical record must clearly 
document the rationale for the performance of a motor threshold redetermination.   
 
Retreatment 
 
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 is considered not medically reasonable and necessary and 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 in the Local Coverage Determination (LCD) - L37086, 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.