Transcranial magnetic stimulation (TMS) is becoming a more viable option for the treatment of depression in youth and adults, providing hope for those with treatment-resistant depression.
Of the roughly 22 million American adults who experienced a major depressive episode in 2023, about 30% have treatment-resistant depression, meaning that multiple medications have failed to alleviate their symptoms.
While all major health plans cover TMS services, prior authorization and fail-first policies act as significant barriers for patients seeking care. These challenges illustrate the hurdles that the behavioral health industry faces as payers increasingly accept TMS but maintain a degree of skepticism about the treatment.
“The insurance landscape around TMS is incredibly complex and constantly evolving,” Dr. Cory Weissman, Medical Director of Interventional Psychiatry at UC San Diego Health, told Behavioral Health Business. “We’ve been finding that it’s incredibly difficult to approach the whole process of insurance authorization and know ahead of time who is going to be qualified for what. We’re also very concerned about [how restrictive] insurance companies are in terms of allowing patients to get TMS.”
Providers must battle expensive up-front costs when providing TMS services, potentially contributing to payers’ sometimes extensive requirements to cover the treatment. Still, health plans are progressively softening these requirements and increasing coverage for adolescents.
For TMS providers, access may be a larger problem than payer policies.
“There is a huge need to drive greater awareness of this as a non-drug alternative,” Keith Sullivan, president and CEO of TMS equipment supplier Neuronetics. “I don’t need to fight the insurance companies. There are plenty of patients that qualify for our treatment. We just need to drive awareness of it so that they know that it’s out there.”
Malvern, Pennsylvania-based Neuronetics owns NeuroStar Advanced Therapy, the first TMS device to be approved by the FDA for adults with major depressive disorder. Neuronetics is the only U.S.-based manufacturer of TMS devices, according to Sullivan. The company claims to be the largest TMS player globally and has delivered 6.6 million treatments to more than 182,000 patients.
Expensive but cost-efficient
TMS is delivered through an expensive device for providers to install and requires specialized clinicians to administer the treatment. Insurance companies are, in turn, expected to pay a “relatively decent amount of money” for each treatment, according to Weissman.
Despite the up-front costs, TMS is cost-effective in the long term. While antidepressants are cheaper than TMS, offering an effective alternative to multiple trials of different pharmaceuticals prevents expensive emergency department visits, Sullivan said.
Research has demonstrated that 54% of patients respond to TMS treatment with a 50% reduction in symptoms.
Payers each have their own internal economic policies that guide how they approach TMS coverage, Weissman said.
“It is important for Aetna to cover a broad selection of evidence-based treatments, as every member is an individual, and a specific treatment that works for one member may not be the right treatment for another member,” Dr. Taft Parsons III, vice president and chief psychiatric officer for CVS Health, told BHB in an email. “That said, we also have a responsibility to ensure that these treatments are safe, evidence-based, and cost-effective.”
Aetna evaluates new treatments based on those three factors, Parsons said, before covering a particular treatment. The health plan covers a maximum of 30 TMS sessions, plus six tapering sessions, for eligible patients. Patients are required to have failed to respond to two antidepressants from at least two different classes at their highest tolerated labeled dose for at least eight weeks and to have received at least eight weeks of augmentation therapy, which involves adding a second medication to an existing antidepressant regime.
California Medicaid (Medi-Cal) is among the health plans that added TMS coverage for adolescents ages 15 and older with major depressive disorder. The payer did not share with BHB the specific factors that drove its decision to add TMS coverage for adolescents.
“[The California Department of Health Care Services] (DHCS) is responsible for evaluating successful interventions to treat mental illness among the Californians we serve,” Ann Carroll, spokesperson for DHCS, told BHB in an email. “TMS is a promising new practice approved by the federal FDA and supported by DHCS. TMS is one of many therapeutic modalities covered under the existing Medi-Cal benefits structure.”
Medi-Cal did share that it was adding coverage for several advanced innovative behavioral health services besides TMS, including dyadic therapy, enhanced care management (ECM) and contingency management.
In many cases, health plans are raising reimbursement rates for TMS services, Sullivan said. He predicts that health plans in some states, including California, Utah and Colorado, have not yet increased rates but are likely to do so in the future.
Shifting fail-first policies
The FDA first approved TMS, specifically Neurostar, in 2008 for adults with major depressive disorder who had tried and failed one or more antidepressant medications. Neuronetics business “really took off” in 2016 when payers started to cover TMS services, Sullivan said.
When payers first began covering TMS, they required adults to have failed four drugs before they would cover TMS.
Payers’ reluctance to cover TMS as a second-line treatment as cleared by the FDA has diminished over the years. Most now require patients to fail two other treatments instead of four, Sullivan said.
Requiring patients to fail two alternative treatments is more reasonable, Weissman said. Weissman, along with several co-authors, published an article in the Journal of Clinical Psychiatry in 2023 that detailed health plans’ TMS requirements. At the time of publication, 10 of the studied health plans required patients to fail two drugs. Thirteen health plans required four.
Health plans’ restrictions on TMS, including requirements to fail four drugs, are concerning, Weissman said. The tide may be turning, albeit slowly. Since the article’s publication, about two of the health plans that required four failed drugs now only require two.
“There’s more and more pressure between insurance companies to maintain competitiveness and attract individuals who may want this treatment,” Weissman said.
Access to TMS overall is still restrictive, Weissman said, but is moving in the right direction.
Cutting the requirement of failed treatments from four to two can give patients access to TMS as much as a year before they would otherwise get it, Sullivan said. He attributes the softening of payer requirements to appeals from physicians.
“They are paying attention to the mental health crisis and listening to all of the [presidential] administrations,” Sullivan said. “Trump was talking about the mental health crisis, now Biden is talking about the mental health crisis. I’m not sure they’ve all done a ton for it, but they have driven awareness, and I think the payers are responding to it.”
Increasing coverage for teens
Coverage for adolescents is beginning to catch on as well.
In March, the FDA approved Neurostar TMS therapy for adolescents aged 15 to 21 with major depressive disorder, which Sullivan called a “big win.” Since then, several payers have added coverage for TMS for adolescents, including Humana, Aetna, California Medicaid, BlueCross BlueShield Michigan and Cambia Health.
Prior to the FDA’s approval of TMS, adolescents only had two options for depression treatment: Prozac and Lexapro.
While there are fewer studies on TMS for adolescents, there are strong signals for its efficacy and high demand from adolescents and parents for effective, safe treatment, Weissman said. He predicts that coverage for TMS youth services will become widely adopted as one method to combat the youth mental health crisis.
“We think TMS should be allowed in a more generalizable population, [who] should more easily be able to access the treatment.”
Since the FDA’s approval, there have been about 425 claims for TMS services for adolescents, Sullivan said. None of these claims have been rejected, he told BHB.
“I anticipate all of the payers are going to follow suit [and cover TMS for teens],” Sullivan said. “They just have to get enough claims from physicians submitted, and then they’ll change. Nobody is going to fight getting a child treated.”
Sullivan anticipates that all major payers will provide TMS coverage for adolescents 15 years of age and older within the next two years.
Companies featured in this article:
