Prior authorization for TMS or Spravato requires documentation of major depressive disorder, failure of typically two to four adequate antidepressant trials, a trial of psychotherapy, and a severity score such as the PHQ-9. Stedfast Psychiatry assembles and submits the request; most decisions come back within 5 to 15 business days. Denials usually stem from missing documentation and are often reversed.
Deep TMS and Spravato are both covered by most insurance plans and by Medicare. That is the good news. The complication is that nearly every payer requires prior authorization before the first session, which means a packet of documentation has to be assembled, submitted and approved before treatment begins. Patients often hear "prior auth" and picture weeks of phone calls. At Stedfast Psychiatry our staff handle the process, but understanding how it works makes the wait easier and helps you supply the records that speed it up.
What prior authorization is
Prior authorization is an insurer's review of whether a proposed treatment meets its medical necessity criteria before it agrees to pay. For low-cost services it is rarely required. For a TMS course, which involves 36 sessions, or Spravato, which is a brand-name drug given in a monitored setting over months, insurers want to confirm that the patient fits the population in which the treatment has been shown to work. In practice that means treatment-resistant depression, documented in a specific way.
The criteria, payer by payer
Each insurer publishes its own medical policy, and they differ in details, but the core requirements are consistent.
| Requirement | Deep TMS | Spravato |
|---|---|---|
| Diagnosis | Major depressive disorder, single or recurrent episode, moderate to severe; some plans also cover OCD | Treatment-resistant major depressive disorder, or MDD with acute suicidal ideation or behavior |
| Failed antidepressant trials | Usually 2 to 4 trials from at least two classes, each at an adequate dose for at least 4 to 6 weeks, in the current episode (Medicare: generally 4 in some regions) | At least 2 trials at adequate dose and duration in the current episode; some plans require augmentation trials |
| Psychotherapy | A documented trial of evidence-based psychotherapy, or a reason it was not feasible | Often required or strongly preferred |
| Severity measure | PHQ-9, BDI, HAM-D or MADRS score in the moderate to severe range at baseline | Same; baseline score required and repeated during treatment |
| Exclusions | Seizure disorder, metal implants in or near the head, active psychosis, current substance use disorder (varies) | Aneurysmal vascular disease, intracerebral hemorrhage history, uncontrolled hypertension, pregnancy, certain substance use histories |
| Ongoing authorization | Initial course approved; retreatment requires documented prior response and relapse | Induction approved first; maintenance requires documented response, typically a 50 percent score reduction |
| Must be given with | Nothing specific; most patients continue their antidepressant | An oral antidepressant, per the FDA label |
Medicare does not use prior authorization in the commercial sense for Original Medicare, but it applies local coverage determinations with similar criteria, and the documentation must be in the chart to survive a post-payment audit. Medicare Advantage plans do require prior authorization and generally follow the local coverage determination plus their own policy.
What we assemble
The authorization packet typically includes: the evaluation note with diagnosis and history; a medication history listing each antidepressant, dose, duration, and reason for stopping, which is why your pharmacy records and prior psychiatric notes matter; a psychotherapy history; a current severity score; a statement of medical necessity from the treating psychiatrist; and, for TMS, a screening for contraindications. For Spravato, the packet also confirms that the clinic is certified under the REMS program and that the patient is enrolled.
The single most useful thing you can do is bring or authorize us to obtain your prior records. A medication list from memory ("I tried Prozac and something else a few years ago") is the most common gap. Pharmacy printouts and old psychiatric notes turn "something else" into "venlafaxine 150 mg for 10 weeks, discontinued for lack of response," which is what the reviewer needs to see.
How long it takes
Most commercial insurers respond within 5 to 15 business days of a complete submission. Some return decisions within 72 hours for standard requests; urgent requests, which apply when the patient has active suicidal ideation, must by regulation be answered faster, often within 72 hours. Medicare Advantage plans are subject to federal timelines of 14 days for standard requests and 72 hours for expedited ones, with 2024 rules shortening these further for some plans. Incomplete submissions restart the clock, which is why we check the packet against the plan's published criteria before sending it.
Why requests get denied
In our experience, the large majority of denials are administrative rather than clinical.
- Inadequate documentation of antidepressant trials: dose or duration missing, or a trial that was too short to count.
- The trials were in a prior episode rather than the current one, and the plan requires current-episode failures.
- No documented psychotherapy trial and no explanation of why.
- Severity score missing or in the mild range.
- A plan-specific requirement, such as a required augmentation trial, that was not addressed.
- For Spravato: no oral antidepressant on board, or blood pressure documentation missing.
- The wrong code or a clerical error, which is more common than anyone would like.
Clinical denials, where the reviewer disagrees that treatment is necessary despite complete documentation, are less common and are the ones worth fighting hardest.
Appeals and peer-to-peer reviews
Every denial comes with appeal rights. The first step is usually a peer-to-peer review, in which our psychiatrist speaks directly with the insurer's reviewing physician, walks through the history and addresses the stated reason for denial. A substantial share of denials are overturned at this stage, particularly when the issue was documentation that can be clarified in conversation.
If the peer-to-peer fails, a formal written appeal follows, with additional records and a letter of medical necessity. Commercial plans have internal appeal levels and then an external review by an independent organization, which is binding on the plan. Medicare Advantage denials can be appealed through a defined multi-level process. State insurance regulators in both Florida and South Carolina also accept complaints about improper denials. Our staff manage the appeal and keep you informed; you may be asked to sign an authorization or provide a statement about how depression has affected your work and daily life, which strengthens the case.
What happens while you wait
Treatment does not have to stall. We can optimize your current medication, start or continue therapy, and, if you are a Spravato candidate, complete the REMS enrollment and baseline measures so that the first session can be scheduled the day approval arrives. For TMS, the motor threshold determination and treatment mapping are done at the first session, so there is no preparatory delay once authorized. If you are in crisis during the wait, tell us; expedited review exists for exactly that situation.
If authorization is denied for good
A small number of patients exhaust appeals. At that point the options are self-pay, which for TMS is a defined course cost and for Spravato is the drug cost plus monitoring with possible manufacturer assistance, or a different treatment path such as further medication augmentation or, for the most severe cases, ECT, which has its own authorization process. We discuss these honestly, including whether a self-pay course is realistic for you.
What to expect from Stedfast Psychiatry
Our Deep TMS program at Palm Beach Gardens and our Spravato programs at Boynton Beach, Palm Beach Gardens and Royal Palm Beach have dedicated staff who submit authorizations daily and know the criteria of the major Florida and South Carolina payers and Medicare Advantage plans. Before we submit, we tell you what your plan requires and whether your history meets it, so that a denial is not a surprise. After we submit, we track the request and call you with the decision. If it is denied, we tell you why in plain terms and what we are doing about it. The process is bureaucratic, but it is navigable, and most patients who meet the criteria are approved.
Frequently asked questions
How many antidepressants do I have to fail before insurance covers TMS?
Most commercial plans require two to four adequate trials from at least two medication classes in the current episode, each at a therapeutic dose for four to six weeks or more. Medicare local coverage determinations have their own counts, sometimes up to four. Documentation of dose and duration is essential.
How long does prior authorization take for Spravato?
Most decisions arrive within 5 to 15 business days of a complete submission. Urgent requests for patients with active suicidal ideation are reviewed faster, often within 72 hours. Incomplete submissions restart the clock, so prior medication records speed things up considerably.
What if my prior authorization is denied?
Most denials are about missing documentation and are often reversed through a peer-to-peer review between our psychiatrist and the insurer's reviewer. If that fails, a written appeal and then an independent external review follow. Stedfast Psychiatry manages the process and keeps you informed.
Does Medicare require prior authorization for TMS?
Original Medicare does not use prior authorization but applies local coverage criteria that must be documented in the chart. Medicare Advantage plans do require prior authorization and generally follow the local coverage determination plus their own policy. Stedfast Psychiatry handles both.
Do I have to be on an antidepressant to get Spravato approved?
Yes. The FDA label specifies that Spravato is used together with an oral antidepressant, and insurers require documentation that one is in place. Most patients continue the antidepressant they are already taking.
Related reading
- How Much Does TMS Cost With and Without Insurance?
- How Much Does Spravato Cost?
- Is TMS Covered by Medicare?
- Does Medicare Cover Spravato?
- Treatment-Resistant Depression: What to Try Next
This article is educational and does not replace evaluation by a licensed clinician. If you are in crisis, call or text 988.