Does Medicare Cover TMS in California?

Does Medicare cover TMS?

Yes. Medicare Part B covers TMS for severe major depressive disorder when standard treatments have not worked and the coverage criteria are met. Coverage is set by regional rules, and in California those are administered by Noridian.

Here is how Medicare covers TMS, what it costs, and how to start.

How Medicare covers TMS

Medicare does not have one national TMS policy. Each regional contractor sets a Local Coverage Determination (LCD). In California, that contractor is Noridian, and its LCD spells out who qualifies and what documentation is needed.

• Diagnosis: severe major depressive disorder, based on the DSM-5-TR.
• Prior treatment: documented failure of antidepressant trials. The required number has eased over time and varies by region, so your provider confirms what applies to you.
• Course: daily outpatient sessions for up to about six weeks, roughly 30 sessions.

Traditional Medicare vs. Medicare Advantage

Traditional Medicare (Part B): covers TMS under the LCD. After your Part B deductible, you generally pay 20 percent of the Medicare-approved amount, unless a Medigap supplement plan covers that share.

Medicare Advantage (Part C): must cover at least what Part B covers, and often handles your cost-sharing differently. Advantage plans may add their own prior-authorization step.

What TMS costs with Medicare

With traditional Medicare and no supplement, your share is about 20 percent per session after the deductible. With a Medigap plan or many Advantage plans, your out-of-pocket can be much lower. We verify your specific coverage before you start. See our TMS cost guide for the full picture.

What about maintenance sessions?

Medicare covers the initial acute course for an eligible diagnosis. Coverage for ongoing maintenance sessions is more limited and varies, so those may be out of pocket. Your provider will tell you what your plan allows.

How to start TMS with Medicare

1. See a provider who offers TMS and accepts Medicare. They confirm whether you meet the LCD criteria.
2. Documentation. Your diagnosis and past antidepressant trials are documented to meet Noridian’s requirements.
3. Begin treatment, usually a daily schedule over about six weeks.

Does Exxceed Wellness accept Medicare?

Yes. We accept Medicare for TMS. If you have Medicare and depression that has not improved on medication, we confirm whether you meet the coverage criteria, handle the paperwork, and treat you at our Hayward clinic. Contact us to check your Medicare coverage, or learn more about our TMS program.

Frequently asked questions

Does Medicare cover TMS for depression?

Yes, for severe major depressive disorder that has not responded to standard treatment, under the regional Local Coverage Determination. In California, Noridian administers this.

How much does TMS cost with Medicare?

With traditional Part B and no supplement, about 20 percent of the approved amount per session after the deductible. A Medigap or Medicare Advantage plan can lower that considerably.

Does Medicare cover TMS for OCD?

Medicare’s TMS coverage is for major depressive disorder. OCD and other uses are generally not covered under the depression LCD, so ask before you start.

How many sessions does Medicare cover?

Daily sessions for up to about six weeks, roughly 30 sessions, when criteria are met.

References

1. Medicare Local Coverage Determination, Transcranial Magnetic Stimulation (California, administered by Noridian): Noridian LCD.
2. CMS Medicare Coverage Database. Local Coverage Determination: Transcranial Magnetic Stimulation in the Treatment of Adults with Major Depressive Disorder: CMS MCD.
3. Perera T, et al. The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation. 2016;9(3):336-346: PubMed.

Educational information only, not medical or financial advice. Medicare coverage and criteria for TMS vary by regional contractor and plan, and can change. TMS is FDA-cleared for major depressive disorder and, as an add-on, for OCD. Other uses may be off-label and may not be covered. Confirm your eligibility and benefits with a qualified clinician and Medicare.