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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 417.414. 
 
The rules state that TMS may be covered if prescribed and administered by a licensed physician who is 
knowledgeable 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 (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 are experimental and are not covered. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L34641: 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.