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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 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 at least 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 (see Retreatment[s] below for previous 
response criteria); 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. 
 
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 retreatment) is written by a psychiatrist (MD or DO), who has examined the 
patient and reviewed the record. 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). 
 
You can find this rule in the Local Coverage Determination (LCD) - Repetitive Transcranial Magnetic 
Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L34998) - Effective 
September 26, 2019. 
 
The rules say that retreatments may be considered medically reasonable and necessary for patients who meet 
ALL of the following criteria: 
 
1. Patients must have 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). 
2.  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). 
 
You can find this rule in the Local Coverage Determination (LCD) - Repetitive Transcranial Magnetic 
Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L34998) - Effective 
September 26, 2019. 
 
The rules say that retreatment(s) that occur 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. You can 
find this rule in the Local Coverage Determination (LCD) - Repetitive Transcranial Magnetic Stimulation 
(rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L34998) - Effective September 26, 
2019. 
 
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.