“Nobody will object to the treatment of a child”: Funding bodies are more willing to cover TMS

Transcranial magnetic stimulation (TMS) is becoming a viable option for treating depression in adolescents and adults, offering hope for people with treatment-resistant depression.

Of the approximately 22 million American adults who experienced a major depressive episode in 2023, about 30% will suffer from treatment-resistant depression, meaning that multiple medications have failed to relieve their symptoms.

Although all major health insurance plans cover TMS services, prior authorizations and fail-first policies present significant barriers for patients seeking treatment. These challenges illustrate the hurdles facing the mental health care industry as payers increasingly accept TMS but maintain some 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 have found that it is incredibly difficult to address the entire insurance approval process and know in advance who will qualify for what. We are also very concerned about [how restrictive] Insurance companies are cautious about admitting patients to TMS.”

Providers face high upfront costs in providing TMS services, which may contribute to payers' sometimes high requirements for treatment. Yet health insurers are increasingly relaxing these requirements and increasing coverage for adolescents.

For TMS providers, access can be a bigger problem than payer policies.

“There is a tremendous need to get this out there as a drug-free alternative,” said Keith Sullivan, president and CEO of TMS equipment supplier Neuronetics. “I don't have to fight the insurance companies. There are many patients who are eligible for our treatment. We just need to raise awareness so they know it's out there.”

Neuronetics, based in Malvern, Pennsylvania, owns NeuroStar Advanced Therapy, the first TMS device 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 world's largest TMS provider and has performed 6.6 million treatments on more than 182,000 patients.

Expensive but cost-effective

TMS is delivered via an expensive device that providers must install and requires specialized doctors to administer the treatment. Insurance companies, in turn, are expected to pay a “relatively decent amount” for each treatment, Weissman said.

Despite the initial cost, TMS is cost-effective in the long run. While antidepressants are cheaper than TMS, an effective alternative to multiple trials of different drugs avoids expensive emergency room visits, Sullivan said.

Studies have shown that 54% of patients respond to TMS treatment with a 50% reduction in symptoms.

Each of the payers has its own internal economic policies that govern how it handles TMS coverage, Weissman said.

“It is important that Aetna cover a broad range of evidence-based treatments because each member is an individual and a particular treatment that works for one member may not be right for another member,” said Dr. Taft Parsons III, vice president and chief psychiatrist at CVS Health, in an email to BHB. “However, 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 must have had no response to two antidepressants from at least two different classes at the highest tolerated dose for at least eight weeks and have received augmentation therapy, which adds a second drug to an existing antidepressant, for at least eight weeks.

California Medicaid (Medi-Cal) is among the health plans that have added TMS coverage for youth ages 15 and older with major depressive disorder. The payer did not tell BHB what specific factors led to its decision to add TMS coverage for youth.

“[The California Department of Health Care Services] (DHCS) is responsible for evaluating successful interventions to treat mental illness among the Californians we serve,” said Ann Carroll, DHCS spokesperson, in an email to BHB. “TMS is a promising new method approved by the FDA and supported by DHCS. TMS is one of many therapeutic modalities covered under the existing Medi-Cal benefits structure.”

Medi-Cal said that in addition to TMS, it is expanding coverage for several advanced, innovative behavioral health services, including dyadic therapy, enhanced care management (ECM) and emergency management.

In many cases, health insurers are increasing reimbursement rates for TMS services, Sullivan said. He expects that in some states, including California, Utah and Colorado, health insurers have not yet increased rates but are likely to do so in the future.

Changed fail-first policy

The FDA first approved TMS, specifically Neurostar, in 2008 for adults with major depressive disorder who had tried one or more antidepressants without success. Neuronetics' business “really took off” in 2016 when payers began covering TMS services, Sullivan said.

When payers first began covering TMS, they required adults to fail four medications before they would cover TMS.

Payers' reluctance to cover TMS as a second-line treatment, as approved by the FDA, has diminished over the years. Most now require patients to undergo two unsuccessful other treatments instead of four, Sullivan said.

It's more reasonable to require patients to fail two alternative treatments, Weissman said. Weissman, along with several co-authors, published a 2023 article in the Journal of Clinical Psychiatry detailing insurers' TMS requirements. At the time of publication, 10 of the insurers studied required patients to fail two drugs. Thirteen insurers required four.

Insurance company restrictions on TMS, including the requirement that four drugs fail, are concerning, Weissman said. The tide may be turning, albeit slowly. Since the article was published, about two of the insurance companies that required four drugs to fail now require only two.

“The pressure among insurers to remain competitive and attract people who want this treatment is increasing,” Weissman said.

Access to TMS is still restrictive overall, said Weissman, but the trend is going in the right direction.

Reducing the number of unsuccessful treatments from four to two could give patients access to TMS a year earlier than they otherwise would, Sullivan said. He attributed the loosening of payer requirements to objections from doctors.

“They are paying attention to the mental health crisis and listening to everyone, [presidential] “Governments,” Sullivan said. “Trump talked about the mental health crisis, now Biden is talking about the mental health crisis. I'm not sure they've all done much to address that, but they've raised awareness, and I think payers are responding.”

Better protection for teenagers

Reporting on young people is also beginning to gain ground.

In March, the FDA approved Neurostar TMS therapy for adolescents ages 15 to 21 with major depressive disorder, which Sullivan called a “huge success.” Since then, several payers have added coverage for TMS for adolescents, including Humana, Aetna, California Medicaid, BlueCross BlueShield Michigan and Cambia Health.

Before the FDA approved TMS, adolescents had only two options for treating depression: Prozac and Lexapro.

Although there are fewer studies on TMS for adolescents, there is strong evidence of its effectiveness and high demand from adolescents and parents for an effective, safe treatment, Weissman said. He expects reimbursement for TMS youth services will become widespread as a method to combat the adolescent mental health crisis.

“We think that TMS should be allowed in a more general population, [who] should have easier access to treatment.”

Since FDA approval, about 425 applications have been submitted for TMS services for adolescents, Sullivan said. None of those applications have been denied, he told BHB.

“I assume that all payers will follow this example. [and cover TMS for teens]”Sullivan said. “They just need to get enough claims from doctors and then they'll change. No one will object to a child being treated.”

Sullivan expects that all major payers will offer TMS coverage for youth ages 15 and older within the next two years.