New TMS Requirements and Expanded Coverage: You Need to Know
As of recent updates, Select Health has outlined new requirements for patients considering Transcranial Magnetic Stimulation (TMS) therapy. These changes are designed to streamline the process and ensure that those who can benefit most from TMS have access to it. Additionally, several major insurance providers have expanded their coverage to include TMS for younger patients.
Here’s what you need to know:
New TMS Requirements for Select Health Patients
1. Recommendation by Psychiatrist or Psych APRN: TMS must be recommended by a psychiatrist or psych APRN who has seen the member face-to-face. Virtual consultations are also acceptable, making it easier for patients to obtain the necessary recommendation.
2. Exclusion of FNP Co-signs: If a Family Nurse Practitioner (FNP) sees the member face-to-face, the psychiatrist cannot simply co-sign. The psychiatrist must be the provider who directly sees the member.
3. Medication Failure Criteria: Patients must have failed 4 medications from two different drug classes within the last 12 months. These medications can be anti-depressants or augmentation agents such as Abilify. The medications must have been tried for more than 4 weeks and shown issues with side effects or non-response. Notably, these medications no longer need to be prescribed or followed by a psychiatric provider.
4. Psychotherapy Trial: A trial of psychotherapy at any point in the member's lifetime is now required. However, there is no need to provide individual therapy notes. Documentation should include the therapist’s name and the date range the member saw each therapist. Specific dates are not necessary, simplifying the documentation process.
Expanded Insurance Coverage for TMS
Several insurance providers have now expanded their coverage to include TMS for younger patients, recognizing its effectiveness in treating Major Depressive Disorder (MDD).
Here are the details:
Aetna: Aetna, covering 19.4 million lives, now covers TMS for candidates aged 15 and older, effective immediately. The coverage criteria specify that TMS treatment must be administered by an FDA-cleared device in accordance with FDA-labeled indications.
California Medicaid (Medi-Cal): Effective August 1, 2024, Medi-Cal includes TMS coverage for adults and adolescents aged 15 and older with MDD. This policy impacts 14.8 million covered lives in California.
BCBS Michigan: BCBS Michigan, covering 4.9 million lives, now includes TMS access for members aged 15-70 years, effective September 1, 2024.
Cambia Health Solutions: Cambia Health Solutions, the parent company of Regence BCBS, Asuris Health, and BridgeSpan Health, covers 2.5 million lives throughout Washington, Utah, Oregon, and Idaho. Their policy allows TMS eligibility for ages consistent with NeuroStar’s FDA indications for ages 15 and older, effective September 1, 2024.
These updates represent a significant step forward in making TMS more accessible to those in need. By adjusting the requirements and expanding coverage, Select Health and other major insurance providers are helping to ensure that patients have access to effective treatment options for depression. If you or a loved one might benefit from TMS, be sure to discuss these changes with your healthcare provider.
