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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 Repetitive Transcranial Magnetic Stimulation (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 electroconvulsive therapy (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. 
 
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. 
 
4. The order for treatment (or re-treatment) 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. 
You can find this information in the he Centers for Medicare & Medicaid Services (CMS) local coverage 
determination (LCD) Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant 
Major Depressive Disorder (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.