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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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that 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: 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). 
 NPPs providers may order treatment (or retreatment) if it is within the scope of practice of the NPP in 
the State they are licensed. It is expected that the NPP has examined the patient, reviewed the record 
and has experience administering TMS therapy. The treatment shall be given under direct supervision 
of this NPP. 
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. 
You can find this rule in 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.