CMS issued guidance encouraging Medicare Advantage plans to adopt standardized prior authorization criteria for transcranial magnetic stimulation, citing significant variability across plans that had created access barriers for beneficiaries. The recommended standardized criteria mirror traditional Medicare's coverage policy and are intended as a floor, not a ceiling.
An analysis cited in the guidance found that prior authorization denial rates for TMS varied from 4% to 38% across Medicare Advantage plans, with no consistent relationship to clinical appropriateness. Wait times for authorization decisions also varied widely, from 3 to 22 days.
The guidance is non-binding but signals heightened CMS attention to behavioral health access in Medicare Advantage. Plans that do not align with standardized criteria may face additional scrutiny in the next round of star ratings.
Patient advocacy groups welcomed the guidance but called for binding regulation rather than guidance. The Medicare Rights Center noted that authorization barriers disproportionately affect older adults with depression who already face significant treatment access challenges.
Source
Reporting based on coverage from CMS. This article is editorial summary intended for general information; it is not medical advice.