Does Ambetter Cover TMS Therapy?

Jump to Section

Does Ambetter Cover Transcranial Magnetic Stimulation (TMS)?

Yes, Ambetter insurance covers Transcranial Magnetic Stimulation (TMS). However, Ambetter TMS guidelines state that prior authorization requests for Ambetter TMS treatment must include numerous items,¹ including a Physician’s Health Questionnaire-9 (PHQ-9) score and the assessment date.

How to Verify Ambetter Coverage for TMS Therapy

Athena Care has multiple TMS clinics in Tennessee that are in-network with most major insurance plans. Find out if your insurance provider can help with the costs by calling your insurance company or by contacting us below. One of our care coordinators can help you navigate your insurance coverage and help you get the care you need.

Ambetter TMS Coverage Eligibility Policy

Ambetter TMS guidelines require the following in any prior authorization requests for Ambetter TMS therapy:

• Identifying information
• Provider name, NPI, TIN
• Servicing provider credentials
• The quantity of each service code requested
• The beginning, end, and length of the requested treatment
• Current DSM diagnoses
• Score on the Physician’s Health Questionnaire-9 (PHQ-9) and the date of the evaluation
• The course of treatment and its results, including the timing and length of the following:

• Medication – specify the kind and level
  • Psychotherapy: Detail the techniques employed
  • Electroconvulsive therapy.
    • *Note: If a member is unable to take medicine or it is not advised to use electroconvulsive therapy, please explain why
• Current therapies and results, such as previously mentioned forms of therapies
• Any relevant medical conditions
• Substance abuse, if any
• Any risky activities, including suicidal or homicidal thoughts
• If more sessions are requested after the initial TMS treatment, and there has been no improvement or reaction, please explain why

What is Transcranial Magnetic Stimulation?

Transcranial Magnetic Stimulation (TMS) is a non-invasive technique that delivers magnetic pulses to a specific area of the brain in patients with Treatment Resistant Depression (TRD) and other psychiatric and neurological illnesses.

A tiny coil that produces a quickly alternating current is applied to the scalp by a licensed mental health professional. By passing through the scalp and bone without impeding it, the magnetic field created by the electrical current stimulates brain activation.

Patients with specific medical implants are not eligible for TMS therapy treatments, as complications can arise from metallic implants or devices that interact with magnetic fields. For example, if you have stents, implanted stimulators, a pacemaker, a medicine pump, cochlear implants, or gunshot fragments in your body, you may not be qualified for TMS therapy. Therefore, discussing these concerns with your doctor beforehand is essential to prevent harmful side effects from TMS therapy.

Additionally, this therapy should be avoided by those with specific medical conditions, such as those with a history of seizures, bipolar disorder, or pregnancy. Finally, inform your TMS clinician about any prescription or over-the-counter medications, supplements, or vitamins you’re taking, as certain drug combinations can cause serious complications.

How Much Does TMS Cost Without Insurance?

These are the typical TMS therapy expenses without Ambetter TMS coverage or other health insurance. These prices could differ based on your location and other variables. Therefore, they might not represent what you pay in Tennessee.

TMS therapy commonly costs between $400 and $500 per session.² However, because most patients require multiple sessions to achieve the best outcomes, the entire cost of TMS therapy may be close to $15,000.

Sources

1. “Notice: Transcranial Magnetic Stimulation Requests for Ambetter Members.” Ambetter, Celtic Insurance Company, 14 May 2020, ambetter.superiorhealthplan.com/provider-resources/provider-news/notice–transcranial-magnetic-stimulation-requests-for-ambetter-.html.
2. 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