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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 treatment that uses pulsed 
magnetic fields to induce an electric current in a localized region of the cerebral cortex. An electromagnetic 
coil placed on the scalp induces focal current in the brain that temporarily modulates cerebral cortical function. 
Capacitor discharge provides electrical current in alternating on/off pulses. Stimulation parameters may be 
adjusted to alter the excitability of the targeted structures in specific cortical regions. Repetitive TMS (rTMS) 
has been investigated as treatment for pharmacoresistant depression. 
 
TMS parameters include cranial location, stimulation frequency, duration, and intensity. TMS is delivered in 
outpatient settings without anesthesia or analgesia. Typically for the treatment of depression, the coil is located 
over the left prefrontal cortex. The rTMS is performed daily (weekdays) for 6 weeks. There is no need for 
anesthesia or analgesia and there are no restrictions about activities before or after treatment (e.g., driving, 
working, operating heavy machinery). 
 
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. 
 
CGS considers TMS therapy reasonable and necessary when it is furnished in accordance with the accepted 
standards of medical practice, when it is furnished in a setting appropriate to the patients medical needs and 
condition, when it meets but does not exceed the patients medical need and when it is ordered and furnished 
by qualified personnel. It is expected that TMS therapy will be ordered by, and furnished under, the direct 
supervision of a psychiatrist who has experience administering TMS therapy. 
 
TMS therapy not ordered by and furnished under direct supervision, by a psychiatrist will be considered not 
medically reasonable and necessary and not subject to coverage. 
 
Left Prefrontal 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 two trials of psychopharmacologic agents in the current depressive episode from at least two 
different agent classes. 
    At least one of the treatment trials must have been administered at an adequate course of mono- or poly-drug 
therapy; or 
 
    Inability to tolerate psychopharmacologic agents as evidenced by four 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. 
 
Resistance to treatment is defined by a failure to achieve a 50% reduction in depressive symptoms, in 
accordance with objective measures such as PHQ-9 and/or HAM-D, from a pharmacologic trial where the 
medication is administered at the recommended adult dose, per the FDA label, for a period of not less than 6 
weeks. 
 
Psychopharmacologic agent side effects will be considered intolerable, when those side effect are of a nature 
where they are not expected to diminish or resolve with continued administration of the drug 
AND 
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. 
AND 
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 psychiatrist will have experience in administering TMS therapy. The 
treatment shall be given under direct supervision of this psychiatrist (physician present in the area and 
immediately available but does not necessarily personally provide the treatment). 
 
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. 
 
You can find these rules in the Local Coverage Determination (LCD) Transcranial Magnetic Stimulation 
(TMS) L36469. 
 
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.