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Does Aetna Cover TMS Therapy?

Does Aetna Cover TMS Therapy?

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Does Aetna Cover Transcranial Magnetic Stimulation (TMS)?

Yes. Aetna insurance covers and considers Transcranial Magnetic Stimulation (TMS) in a healthcare practitioner’s office medically necessary when certain criteria are met.1

How to Verify Aetna Coverage for TMS Therapy

Look no further than Athena Care for a TMS clinic near you. We are also in-network with most major insurance plans. Therefore, filling out our free, no-obligation online insurance verification form is the most reliable method to begin your Aetna TMS therapy in Tennessee today.

After you’ve submitted the form, one of our highly experienced care coordinators will handle the challenges of contacting your health insurance carrier for more information about Aetna TMS treatment. They’ll review your policy and clearly explain your treatment options. You can rest assured that any information you provide or discuss is confidential.

Aetna TMS Coverage Eligibility Policy

Aetna TMS guidelines for coverage eligibility are as follows:

TMS therapy Aetna deems medically necessary is performed in a health care setting when all of the following criteria are met:2

  • Administered by a device with FDA approval and used per FDA-labeled indications
  • Individual is 18 years or older
  • Individual has a confirmed diagnosis by a psychiatrist of severe Major Depressive Disorder (MDD) (single or recurrent episode), documented by standardized rating scales that accurately measure depressive symptoms (e.g., Beck Depression Scale [BDI], Hamilton Depression Rating Scale [HDRS], Montgomery-Asberg Scale [MADRS])
    • The same depression rating scale must be used throughout the treatment.
  • There is evidence, in the form of legible medical records, that a four-month or longer trial of therapy recognized to be successful in treating Major Depressive Disorder failed to produce significant reductions in depressive symptoms. The participant must have received psychotherapy from a licensed mental health professional.
  • Individual has no contraindications that preclude TMS use (see the list of restrictions below)
  • Individual has not received an adequate response to treatment for the current depressive episode within the last five years. Note: For this policy, the most recent onset of acute symptoms marks the beginning of the current depressive episode. This includes:
    • At least two antidepressants from at least two different classes, each with a different mechanism of action, were used for at least eight weeks each (to qualify as an adequate antidepressant drug trial, the individual’s dose during the unsuccessful attempts had to have been at or above the minimal effective therapeutic dose for that antidepressant); and
    • Augmentation therapy, in addition to the primary antidepressant used for at least eight weeks. The enhancing substance ought to have been at or above the minimal therapeutic dose, which is ordinarily the minimal labeled dose; and
  • A maximum of 30 sessions (5 days per week for six weeks) of therapy are required, plus six tapering sessions (6 sessions over three weeks).
    • The need for treatments that last longer than 36 sessions—for instance, 30 treatment sessions followed by six tapering sessions—may be considered. There isn’t enough data to indicate that people resistant to one brand of repetitive Transcranial Magnetic Stimulation (rTMS) or deep Transcranial Magnetic Stimulation (dTMS) device will be responsive to another brand.
  • An FDA-approved or cleared device is used to administer TMS therapy Aetna uses for treating Major Depressive Disorder.
    • TMS therapy should adhere to the procedure and guidelines listed in the user manual provided by the manufacturer, with alterations made only when justified by established scientific data.
  • A psychiatrist (MD or DO) who has examined the patient, reviewed the record, and determined that TMS is indicated for usage in a particular patient will write the order for treatment (or re-treatment). The psychiatrist should be in charge of initial patient motor threshold assessments, mapping and treatment parameter definitions, and overall planning of each patient’s TMS treatment course. The psychiatrist must attest that this doctor will directly supervise the treatment (i.e., the physician will be in the area and immediately available for each treatment). The psychiatrist should designate appropriately trained persons who can carry out the daily TMS therapy sessions if the proposed physician is not carrying them out. During the patient’s TMS Therapy, the psychiatrist is also in charge of evaluating the patient.
  • A clinical expert doing TMS Therapy under a doctor’s supervision will be the TMS operator. The TMS operator should have the clinical knowledge necessary to monitor the patient while a TMS treatment session is being administered. The operator must watch the patient’s physical condition for the possibility of adverse effects, make routine modifications as necessary and per product labeling, or decide when to consider treatment interruption or termination. The patient should always be in the treatment room with the TMS operator. The operator must be qualified to monitor the patient for seizure activity and administer care for seizure management.

In addition, TMS re-retreatment for depression may be medically necessary when specific criteria are met.

Aetna TMS guidelines consider TMS contraindicated, experimental, and investigational in individuals who exhibit any of the following because safety and efficacy have not been proven:

  • Individuals who have abused drugs with known abuse potential in the past 90 days
  • Individuals who are suicidal
  • Individual has a metal implant in or around the head (such as an eye implant, metal plate, aneurysm coil or clip, or stent)
  • The participant suffers from neurological diseases, such as primary or secondary tumors of the central nervous system, dementia, or cerebrovascular disease, or they have a history of frequent or severe head trauma
  • There are implanted devices, such as a cochlear implant, spinal cord stimulator, cardiac pacemaker or defibrillator, etc.
  • Individual has significant cardiovascular disease

What is Transcranial Magnetic Stimulation?

Transcranial Magnetic Stimulation (TMS) is a non-invasive technique that delivers magnetic pulses to the brain of patients with Treatment Resistant Depression (TRD). Medical professionals are also researching TMS as a potential treatment for many other disorders, including schizophrenia, ADHD, and Post-Traumatic Stress Disorder (PTSD).3

A qualified TMS administrator places a tiny coil on the patient’s head to produce a swiftly alternating current. The magnetic field generated by the electrical current causes brain activity by passing through the scalp and bone without impeding it.

TMS treatment is not available to people with certain medical implants. Complications can arise from metal implants or devices that interact with magnetic fields. Additionally, if you have stents, implanted stimulators, a pacemaker, a medication pump, cochlear implants, or gunshot fragments in your body, you may be ineligible for TMS therapy. To prevent negative side effects from TMS therapy, discussing these concerns with your doctor beforehand is essential.

Furthermore, people with certain medical issues should not receive TMS. For instance, this therapy should be avoided by those with a history of seizures, those diagnosed with bipolar disorder, and those who are pregnant.

Finally, be sure to let your TMS doctor know if you use any prescription or over-the-counter drugs, nutritional supplements, or vitamins. Some drug combinations can have serious side effects.

How Much Does TMS Cost Without Insurance?

Without Aetna TMS coverage or any other insurance coverage, the average cost of TMS therapy can vary by location and other factors, such as an administrator’s credentials. Therefore, the following might not accurately reflect what you pay in Tennessee.

The typical TMS session cost ranges from $400 to $500.4 However, since most patients require multiple sessions to achieve the best outcomes, the entire cost of TMS therapy may be close to $15,000.

Sources

  1. “Transcranial Magnetic Stimulation and Cranial Electrical Stimulation.” Aetna, Aetna Inc., 11 July 2022, www.aetna.com/cpb/medical/data/400_499/0469.html.
  2. “Transcranial Magnetic Stimulation and Cranial Electrical Stimulation.” Aetna, Aetna Inc., 11 July 2022, www.aetna.com/cpb/medical/data/400_499/0469.html#policy.
  3. “Transcranial Magnetic Stimulation (TMS).” Cleveland Clinic, 28 June 2018, my.clevelandclinic.org/health/treatments/17827-transcranial-magnetic-stimulation-tms.
  4. Porter, Robert. “What Does TMS Therapy Cost? TMS Information | BetterHelp Advice.” Betterhelp, BetterHelp, 20 Apr. 2022, www.betterhelp.com/advice/therapy/how-much-does-tms-therapy-cost

If you suspect that you or someone you love suffers from mental health disorders, contact Athena Care today.

One of our friendly associates will help you get the help you need. Take this first step to feel better and take control. 

(615) 320-1155