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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 non-invasive method of brain stimulation. The 
technique involves placement of a small electromagnetic coil over the scalp and applying 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.  
 
When used as an antidepressant therapy, TMS produces a clinical benefit without the systemic side effects 
attendant with standard oral medications. TMS does not have adverse effects on cognition. Unlike 
electroconvulsive therapy (ECT), rTMS does not induce amnesia or seizures. 
 
Indications for Coverage 
TMS may be covered if prescribed and administered by a licensed physician under direct supervision who is 
trained and experienced in the use of repetitive transcranial magnetic stimulation. Outpatient rTMS may be 
indicated for patients with DSM-IV defined Major Depressive Disorder who have failed to benefit from initial 
treatment of their depression.  
 
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 (medical doctor (MD) or doctor of 
osteopathic medicine (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).  
 
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 these rules in the Local Coverage Determination (LCD) Transcranial Magnetic Stimulation 
(TMS) L37088. 
 
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.