Medicaid & Medi-Cal
Coverage For TMS
Medicaid & Medi-Cal
Coverage For TMS
Medicaid and Medi-Cal Insurance Coverage for TMS in California
As of August 1, 2024, California’s Medicaid program, Medi-Cal and Cal Optima in Orange County, began covering transcranial magnetic stimulation (TMS) therapy for adults with major depressive disorder (MDD). This recent policy change is a significant milestone in the accessibility of mental health care, offering new hope to those who have struggled to find effective treatment.
TMS therapy is a non-invasive, FDA-approved treatment for depression that uses magnetic fields to stimulate the brain involved in mood regulation. Unlike traditional therapies, TMS does not require sedation or anesthesia, making it a safer, well-tolerated option for many individuals. The procedure typically involves daily sessions over several weeks, with each session lasting around 30 minutes.
One of the key advantages of TMS therapy is its targeted approach. The magnetic pulses used in TMS can be precisely directed to areas of the brain associated with mood disorders, leading to more effective and efficient treatment outcomes. This precision is particularly beneficial for individuals with MDD who have not responded well to antidepressants or other forms of therapy.
Understanding Your Medi-Cal or Medicaid Insurance Coverage
With the recent update, Medi-Cal now covers transcranial magnetic stimulation (TMS) therapy under specific conditions, making it more accessible to a broader population. The coverage includes the following CPT codes:
- 90867: This code covers the initial therapeutic repetitive TMS treatment, including cortical mapping, motor threshold determination, delivery, and management. This first session is crucial for setting up the treatment parameters tailored to the individual’s medical needs.
- 90868: This code covers the subsequent therapeutic repetitive TMS delivery and management per session. This means that each follow-up session after the initial setup is covered under this code.
- 90869: This code is used for maintenance sessions, which may be necessary to sustain the benefits of TMS therapy over time.
It’s important to note that this applies to adults with MDD who meet the criteria established by Medi-Cal. By including these CPT codes, Medi-Cal has recognized the importance of TMS therapy in treating mental health conditions, providing an alternative to traditional pharmacological treatments.
While TMS therapy has gained recognition as an effective treatment for MDD, its coverage under Medicare varies depending on specific criteria. Medicare typically covers TMS therapy for patients who have been diagnosed with treatment-resistant depression, meaning they have not experienced sufficient improvement from prior antidepressant medications or other forms of therapy. To qualify, certain medical necessity requirements must be met, and the treatment must be administered by a Medicare-approved provider. It’s important for individuals to consult with their healthcare provider and review their Medicare plan to understand the extent of coverage available for TMS therapy.
The Benefits of TMS Therapy
TMS therapy offers numerous benefits, making it an appealing option for those seeking an alternative to medication:
- Non-Invasive: As a non-invasive option, TMS does not require any surgical procedures or anesthesia, which reduces the risk of complications and allows patients to return to their daily activities immediately after each session.
- Drug-Free: For patients who prefer to avoid medications or have not responded well to them, TMS offers a non-pharmacological alternative that can still provide significant relief from depressive symptoms.
- Minimal Side Effects: Compared to other options, TMS has minimal side effects. Some patients may experience mild headaches or scalp discomfort, but these symptoms are generally short-lived and diminish over time.
- Precise Treatment: The ability to target specific areas of the brain makes TMS a more effective and precise treatment choice for major depressive disorder.
- Long-Lasting Results: Research has shown that TMS can produce long-lasting effects, with many patients experiencing sustained improvement in their symptoms for several months or longer after completing the treatment.
The inclusion of TMS in Medi-Cal’s coverage is a significant development for depression care in California. With the cost of TMS ranging from $300 to $600 per session without insurance, many people were previously unable to access this innovative service. Medi-Cal now makes TMS a viable option for a larger segment of the population, reducing financial barriers and expanding access to effective mental health care.
At A Better Way Psychiatry and TMS Clinic, we are dedicated to helping adults in California achieve their mental health goals. If you or a loved one is struggling with major depressive disorder and are interested in exploring TMS therapy, we encourage you to reach out to us. Our team is here to provide comprehensive support, answer any questions you may have, and guide you through the process of determining whether TMS therapy is the right choice for you.
Contact us today to schedule a free consultation and take the first step towards a brighter, healthier future. We offer mental health services throughout the state of California and our clinics are currently accepting new patients!