Prior authorization is a requirement by your insurance company that a treatment be approved in advance before the plan will pay for it. Routine psychiatry visits and most generic medications do not need it. It is commonly required for brand-name or higher-cost medications, for stimulants in some plans, and almost always for Deep TMS and Spravato. The insurer wants documentation that the treatment meets its medical necessity criteria, which for TMS and Spravato usually means a confirmed diagnosis of major depressive disorder, a current symptom score such as a PHQ-9 or MADRS, and a record of prior antidepressant trials with doses, durations and outcomes.
The process is handled by your clinical team. Your psychiatrist documents the history, our staff submit the request through the insurer's portal or by fax, and the plan responds with an approval, a request for more information, or a denial. Turnaround ranges from a few days to two weeks. Denials can be appealed, and a peer-to-peer call between your psychiatrist and the plan's reviewing doctor often resolves them. Approvals typically specify a number of sessions and a time window, and a continuation request is needed to extend treatment. Medicare Part B does not use prior authorization for TMS in the same way but applies coverage criteria through its local coverage determination. Stedfast Psychiatry's staff manage authorizations for TMS and Spravato at the offices where those services are offered.