How I got my insurance to cover TMS after initial denial
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Sign in to commentThis is incredibly helpful. I'm currently at step 2 of your timeline — just got my first denial from Aetna. The 'not medically necessary' language is so frustrating when you've literally tried everything. Going to push for that appeal now.
Same experience with UnitedHealthcare. First denial, then approved on appeal with documentation of 4 failed meds. The whole process took about 6 weeks. One thing I'd add: ask for a peer-to-peer review. That's where your psychiatrist talks directly to the insurance company's reviewing doctor. My psychiatrist said that call is what turned things around.
From the provider side, I want to emphasize how important that peer-to-peer review is. Insurance companies often have non-specialists reviewing TMS claims. When I can speak directly with their reviewer and explain the clinical rationale, approval rates go way up. Also: if your clinic doesn't have an insurance coordinator, consider that a red flag. A good TMS clinic should have staff dedicated to navigating prior authorizations.
For anyone with Medicare — it's been covered since 2021 and the approval process was much smoother for me than what Jennifer describes with private insurance. My out-of-pocket was about $800 total.
Wanted to update: I've since helped two friends navigate the same BCBS appeal process using this exact approach. Both got approved. Don't give up after the first denial!