Medicare and most major insurers in Florida cover TMS for major depressive disorder after documented failure of antidepressant medication, typically two to four trials, plus psychotherapy and PHQ-9 or HAM-D scores. Prior authorization is required for commercial plans and takes one to three weeks. Your cost is then your plan's copay or coinsurance per session. For self-pay rates, ask our TMS coordinator.
This page explains what insurers require, how the authorization process works, what Medicare covers in Florida, and how we handle self-pay for patients whose plans exclude TMS. We do not publish a self-pay rate because protocols vary; our TMS coordinator at Palm Beach Gardens can give you current pricing by phone.
Who it is for
Insurance coverage for TMS is strongest for adults with major depressive disorder who have a clear history of medication trials. Medicare beneficiaries have the most straightforward path in Florida. Patients with commercial PPO or HMO plans from Aetna, Cigna, UnitedHealthcare, Florida Blue, Humana and most Blue Cross plans can expect coverage if they meet the plan's criteria. OCD coverage is available under some plans and denied under others. Smoking cessation and anxious depression as standalone indications are rarely covered, though anxious depression is usually billed under the depression diagnosis. Self-pay patients include those with plan exclusions, those who do not yet meet the medication-trial threshold but want to start now, and those seeking treatment for an off-label indication.
How it works
After your consultation, our TMS coordinator assembles the authorization packet: the psychiatrist's evaluation, your PHQ-9 and any other required scales, a medication history with doses and durations, psychotherapy history, and a contraindication screen. The packet goes to your insurer's behavioral health unit, which is often a separate company from the medical plan. Commercial plans typically respond within 5 to 15 business days. If approved, the authorization specifies a number of sessions, usually 30 to 36, and an expiration date. If denied, the coordinator files a peer-to-peer review, in which our psychiatrist speaks directly with the insurer's reviewer, and if that fails, a formal appeal. A high share of initial denials are overturned on appeal when the documentation is complete.
Medicare's Florida coverage determination for TMS requires severe major depressive disorder, failure of or intolerance to at least one antidepressant, and an order from a psychiatrist after face-to-face evaluation, with an acute course of up to six weeks.
Source: First Coast Service Options, LCD L34522 and billing article A57647
Cost-effectiveness analyses have found TMS to be cost-saving or cost-effective compared with continued medication trials for patients who have failed two or more antidepressants, because of reduced hospitalization and productivity loss.
Source: Voigt, Carpenter and Leuchter, BMC Psychiatry, 2017
Treatment-resistant depression is associated with roughly double the annual health care costs of depression that responds to treatment.
Source: Zhdanava et al., Journal of Clinical Psychiatry, 2021
Only about one third of patients remit on their first antidepressant, and each further medication step has lower remission odds, which is why payers now cover TMS after two to four trials rather than requiring exhaustion of all options.
Source: STAR*D trial, American Journal of Psychiatry, 2006
What to expect
Once authorized, you pay your plan's cost share per session. For a Medicare patient with a supplement plan this is often nothing. For a commercial PPO it is typically a specialist copay or a percentage coinsurance until your out-of-pocket maximum is reached, and many patients hit that maximum partway through a course, after which sessions are fully covered. We verify your benefits and give you an estimate in writing before your first session. Billing uses CPT codes 90867 for the first session with motor threshold mapping, 90868 for each subsequent session, and 90869 if remapping is needed.
Benefits
- Medicare covers TMS for depression in Florida with no prior authorization requirement
- Most major commercial insurers cover TMS for treatment-resistant depression
- Our TMS coordinator handles verification, authorization, peer-to-peer reviews and appeals
- Written cost estimate before you start, based on your verified benefits
- Self-pay and payment options for patients whose plans exclude TMS
Risks and side effects
The financial risk with TMS is starting a course before authorization is confirmed, or exceeding the authorized session count. We do not schedule covered sessions until the authorization number is in hand, and the coordinator tracks remaining sessions so you never receive a surprise bill. If your insurer approves fewer sessions than the protocol calls for, we tell you before you begin so you can decide how to handle the balance.
Cost and insurance
List prices for a full TMS course in the United States generally run into the thousands of dollars, and most of that is covered when you meet criteria. We do not quote a flat self-pay price on this page because the number of sessions in your protocol, whether you need remapping, and whether a maintenance course is likely all affect the total. Ask our TMS coordinator for current self-pay rates and payment plan options; we will give you a written quote for your specific protocol.
What insurers want to see
| Requirement | Medicare (Florida) | Typical commercial plan |
|---|---|---|
| Diagnosis | Severe major depressive disorder | Moderate to severe MDD, single or recurrent |
| Rating scale | Documented severity; scale not mandated | PHQ-9 of 15 or more, or HAM-D of 18 or more, at authorization |
| Failed antidepressant trials | At least 1 (failure or intolerance) | 2 to 4, from at least 2 classes, 6 or more weeks each |
| Psychotherapy | Not mandated | Documented trial, or reason not feasible |
| Ordering provider | Psychiatrist (MD or DO), face-to-face exam | Psychiatrist or psychiatric NP under supervision |
| Prior authorization | Not required | Required |
| Acute course | Up to 6 weeks | 30 to 36 sessions |
| Retreatment | Allowed for prior responders | Usually allowed for prior responders |
Why the medication-trial requirement exists
Insurers position TMS after medication because it costs more per episode than a generic antidepressant and because the pivotal trials enrolled patients who had already failed medication. The STAR*D data give the requirement a clinical rationale: after two failed trials, the odds of remission on a third medication are around 14 percent, which is lower than the remission rate for TMS in the same population. Two failed trials is where TMS starts to look like the better bet, and most plans have landed there or at three.
Documenting your medication history
An adequate trial means a therapeutic dose for at least six weeks, or a shorter trial stopped for intolerable side effects. For each medication, the insurer wants the name, the maximum dose, the start and stop dates, and the reason it stopped. Acceptable sources include pharmacy fill histories, prior psychiatrist or primary care notes, patient portal records and hospital discharge summaries. If you have been treated by Stedfast for medication management, we already have what we need.
The authorization timeline
- Consultation with a Stedfast psychiatrist, in person or by telehealth, with rating scales and contraindication screen.
- Benefits verification by the TMS coordinator, usually within two business days: confirms TMS is a covered benefit, identifies the behavioral health administrator, and estimates your cost share.
- Authorization submission with the full clinical packet.
- Insurer decision, typically 5 to 15 business days. Approved authorizations state the session count and validity window.
- Scheduling of motor threshold mapping and your daily session slot.
- Mid-course review: some plans require updated scores at session 10 or 20 to continue; we submit these automatically.
Self-pay: how it works
If your plan excludes TMS, if you do not yet meet the trial threshold, or if you are seeking treatment for OCD or another indication your plan does not cover, you can proceed as a self-pay patient. We price by protocol and provide a written quote; ask our TMS coordinator for current self-pay rates. Health savings and flexible spending accounts can be used. Some patients choose to start self-pay while an appeal is pending and are reimbursed if the appeal succeeds, though reimbursement is at the insurer's discretion and we cannot guarantee it.
Comparing the cost of alternatives
Treatment-resistant depression is expensive even when nothing is done: more primary care visits, more emergency visits, more lost work and a higher chance of hospitalization. Published cost-effectiveness models find that TMS after two failed medication trials is cost-effective and often cost-saving over a few years compared with continuing to cycle through medications. Spravato is also covered for treatment-resistant depression but requires twice-weekly monitored visits of two hours each during induction and ongoing maintenance dosing, so its total cost over a year is typically higher than a single TMS course. ECT is covered but involves anesthesia, facility fees and a driver for every session.
Deep TMS in Palm Beach Gardens
Stedfast Psychiatry delivers Deep TMS at our Palm Beach Gardens office, 11641 Kew Gardens Ave, Suite 209, just off PGA Boulevard and I-95. Patients travel to us from Jupiter, West Palm Beach, Boynton Beach, Stuart and Royal Palm Beach, and most find the drive manageable because a Deep TMS session takes about 20 minutes and you drive yourself home. Call (561) 437-2199 to schedule a TMS consultation, or ask your current Stedfast provider for an internal referral. Our TMS coordinator handles insurance verification, prior authorization and scheduling so you can start as soon as approval comes through.
Frequently asked questions
Is TMS covered by insurance?
Yes, for major depressive disorder, by Medicare and most major commercial plans in Florida. Coverage requires documentation that you have tried antidepressant medication without adequate relief, usually two to four trials for commercial plans and at least one for Medicare, along with a psychotherapy trial and standardized rating scales. Prior authorization is required for commercial plans. Coverage for OCD is plan-dependent and for other indications is uncommon.
Does Medicare cover TMS?
Yes. Medicare Part B covers TMS for major depressive disorder in Florida under the First Coast Service Options local coverage determination. You need a confirmed diagnosis of severe MDD, failure of or intolerance to at least one antidepressant, and a psychiatrist's order after an in-person evaluation. Medicare covers an acute course of up to six weeks and allows retreatment for prior responders. Medicare Advantage plans follow the same rules but may require prior authorization.
How much does TMS cost with insurance?
Your cost is your plan's specialist copay or coinsurance per session, applied against your deductible and out-of-pocket maximum. Because a course has 36 sessions, many commercial patients reach their out-of-pocket maximum before the course ends, after which the remaining sessions are covered in full. Medicare patients with a supplement plan often pay nothing. We verify your benefits and give you a written estimate before the first session.
How much does TMS cost without insurance?
We do not publish a flat self-pay price because the total depends on your protocol, the number of sessions and whether remapping or maintenance is needed. Ask our TMS coordinator at Palm Beach Gardens for current self-pay rates and a written quote for your situation. Payment plans are available. Many patients who begin as self-pay later qualify for coverage once their medication history is fully documented.
How long does prior authorization take?
Commercial insurers typically respond within 5 to 15 business days of receiving a complete packet, so one to three weeks is a realistic expectation. Delays almost always come from missing medication records, which is why we ask you to bring a complete medication history to the consultation. Medicare does not require prior authorization, so Medicare patients can often start within days of the consultation.
What if my insurance denies TMS?
Most denials are for incomplete documentation rather than a true coverage exclusion. Our coordinator first requests a peer-to-peer review, in which our psychiatrist speaks with the insurer's medical reviewer; many denials are reversed at this stage. If that fails, we file a formal written appeal with additional records. If the plan genuinely excludes TMS, we discuss self-pay options and whether Spravato, which has separate coverage rules, might be an alternative.
Does insurance cover TMS for OCD?
Sometimes. Deep TMS has been FDA-cleared for OCD since 2018, and a growing number of commercial plans cover it, usually after failure of two SSRI trials and a course of exposure and response prevention therapy. Other plans still classify it as investigational. Medicare does not currently cover TMS for OCD under the Florida determination. Our coordinator will check your specific plan before you decide whether to proceed as self-pay.
Will insurance cover a second course of TMS if I relapse?
Usually, if you responded to the first course. Medicare explicitly allows retreatment for patients who showed a documented response previously. Most commercial plans cover retreatment when symptoms return after a period of improvement, typically with a shorter authorization of 10 to 20 sessions. Ongoing scheduled maintenance TMS without a relapse is less consistently covered and is often self-pay.
Where this treatment is offered
Conditions this treats
If you are in crisis, call or text 988 or go to the nearest emergency room. Educational content; individual results vary. Reviewed by Dr. David Husted, board-certified psychiatrist.