Is TMS Covered by Medicare? Rules, Costs and Steps

The short answer

Yes. Medicare Part B covers TMS for major depressive disorder when you have not responded to antidepressant medication, typically one to two adequate trials, and meet other medical criteria. With Original Medicare you pay 20 percent after the Part B deductible; Medigap covers most of that. Medicare Advantage plans cover TMS with their own copays.

Medicare covers TMS for depression. That has been true nationwide for several years, and it matters because depression in older adults is common, undertreated and often resistant to the medications that work for younger people. Here is what Medicare requires, what it pays, and what you can expect to owe.

What Medicare covers

Medicare pays for TMS under Part B, the outpatient medical benefit, as a physician-supervised procedure. Coverage is governed by Local Coverage Determinations issued by the Medicare Administrative Contractors that process claims in each region. Florida and South Carolina fall under First Coast Service Options and Palmetto GBA respectively, and their policies are closely aligned with each other and with national practice.

The covered diagnosis is major depressive disorder, single episode or recurrent, in adults. Medicare does not currently cover TMS for OCD, anxiety disorders, PTSD, bipolar depression or other conditions, even where the device is FDA-cleared for them. Those uses are considered investigational for Medicare purposes.

The medical criteria

To be approved, your record needs to document the following. The exact wording varies slightly between contractors, but the substance is consistent.

A confirmed diagnosis of major depressive disorder, with severity documented by a standardized scale such as the PHQ-9, Beck Depression Inventory or Hamilton rating scale.
Failure of antidepressant medication: no clinically meaningful improvement after at least one, and often two, adequate trials, meaning the medication was taken at a therapeutic dose for a sufficient time, usually four to six weeks. Intolerance to medication due to side effects can count in place of failure.
A trial of evidence-based psychotherapy, or documentation of why it was not appropriate.
No contraindications: no metal implants in or near the head, no uncontrolled seizure disorder.
Treatment ordered and supervised by a psychiatrist, with the psychiatrist present for the initial motor threshold determination and available during sessions.
For a repeat course, documentation that you responded to a prior course and have since relapsed.

Medicare also expects ongoing symptom measurement during the course, and it will not pay for sessions beyond a defined number, typically 36 in the initial course, without documentation of continued benefit.

What you pay with each kind of Medicare

Original Medicare without a supplement

After you meet the annual Part B deductible (around $260 in recent years), Medicare pays 80 percent of the approved amount for each session and you pay 20 percent. Medicare's approved amount for a TMS session is lower than commercial rates, generally in the range of $150 to $250 depending on the session type and region. Twenty percent of that across 36 sessions comes to roughly $1,200 to $1,800, plus the deductible.

Original Medicare with Medigap

A Medigap supplement (Plans G, N and others) picks up the 20 percent coinsurance. With Plan G, you pay the Part B deductible and nothing else. With Plan N, you may owe a small copay per visit. This is the cheapest way to get TMS on Medicare.

Medicare Advantage

Medicare Advantage plans must cover everything Original Medicare covers, including TMS, but they set their own cost sharing and almost always require prior authorization through the plan. Copays for TMS sessions vary from $0 to about $50 per session, and some plans apply coinsurance instead. The plan's network also matters: Stedfast Psychiatry participates in many Medicare Advantage networks in Florida and South Carolina, and we confirm yours before scheduling.

Coverage type	Prior authorization	Typical patient cost for 36 sessions
Original Medicare only	Not formally required; criteria must be documented	Part B deductible plus about $1,200 to $1,800
Original Medicare plus Medigap Plan G	Same	Part B deductible only, about $260
Original Medicare plus Medigap Plan N	Same	Deductible plus up to $20 per visit
Medicare Advantage	Required	$0 to about $1,800 depending on copay
Medicare plus Medicaid (dual eligible)	Varies	Often $0

How approval works in practice

Original Medicare does not run a formal prior authorization program for TMS. Instead, the practice must document that you meet the criteria before treatment and keep that documentation for audit. A claim submitted without the required history can be denied after the fact, which is why a careful practice builds the file first.

Medicare Advantage plans do require prior authorization. The practice submits your diagnosis, rating scale scores, medication history with doses and dates, therapy history and a safety screen. Decisions usually come back within one to two weeks. Denials are most often for incomplete medication documentation and are frequently reversed on appeal.

At Stedfast Psychiatry, the process begins with a psychiatric evaluation at any of our offices or by telehealth, where we gather and document your treatment history. If you qualify, we handle the authorization and give you a written cost estimate before your first session at our Palm Beach Gardens TMS office.

Special considerations for older adults

Depression in later life is often mistaken for normal aging, grief or early dementia, and it is frequently treated with lower doses of medication than younger adults receive because of side effects and drug interactions. That makes older patients good candidates for TMS, which has no systemic side effects and no interactions with other medications. Studies of TMS in patients over 60 show response rates similar to younger adults, particularly when protocols are adjusted for age-related changes in the distance between scalp and cortex.

The daily visit schedule is the main practical challenge. Thirty-six visits over six to nine weeks requires reliable transportation. We schedule standing appointment times and can help coordinate with family members or facility transport.

Common reasons Medicare claims are denied

Three problems account for most denials. The first is a medication history without doses and dates, so the reviewer cannot confirm the trials were adequate. The second is a missing baseline rating scale score. The third is a diagnosis coded as something other than major depressive disorder, such as adjustment disorder or unspecified depression. All three are fixable with a complete evaluation before treatment starts, which is why we gather that history at the first visit rather than after a denial.

If a claim is denied, you have the right to appeal through Medicare's standard redetermination process, and the practice files the appeal with the supporting records. Most well-documented appeals succeed.

Repeat courses and maintenance

Medicare covers a repeat acute course if you responded to a prior course and have relapsed, with the same documentation requirements. Scheduled maintenance TMS, meaning periodic sessions to prevent relapse rather than treat it, is not consistently covered by Medicare and is often self-pay. The practice will discuss options if you reach that point.

Bottom line

Medicare covers TMS for major depression that has not responded to medication, in both Florida and South Carolina. Your cost ranges from essentially nothing with a Medigap supplement to roughly $1,500 to $2,000 with Original Medicare alone, and Medicare Advantage plans fall somewhere in between. The practice does the paperwork; you do the sessions.

Frequently asked questions

How many failed medications does Medicare require before TMS?

Medicare's local coverage policies generally require failure of or intolerance to at least one adequate antidepressant trial, and many reviewers look for two from different classes, each at a therapeutic dose for four to six weeks. A psychotherapy trial is also expected. Your psychiatrist documents this history before treatment begins.

Does Medicare cover Deep TMS?

Yes. Medicare covers TMS as a procedure and does not distinguish between BrainsWay Deep TMS and figure-8 systems for major depressive disorder. Both are billed under the same codes.

Does Medicare cover TMS for anxiety or OCD?

No. Medicare currently covers TMS only for major depressive disorder. Deep TMS is FDA-cleared for OCD and anxious depression, but Medicare has not extended coverage to those uses, which means they would be self-pay for Medicare patients.

Does Stedfast Psychiatry accept Medicare for TMS?

Yes. We accept Original Medicare and many Medicare Advantage plans. Deep TMS is offered at our Palm Beach Gardens office, and the initial evaluation can be done at any of our 13 offices or by telehealth.

Is TMS Covered by Medicare?