There have been a number of interesting and I would even say exciting developments lately at SCTMSC. Because these have bearing on your thinking about the cost and availability of TMS treatment, I am providing an expansion of the previous post.
At Southern Colorado TMS Center (SCTMSC) we keep in touch with other TMS providers around the country and with representatives of Neuronetics, Inc., the manufacturer of our FDA-cleared TMS device. Through these sources we have been hearing for more than a year that there were signs that the wall of resistance from insurance companies which we have experienced might be coming to an end. We’ve learned of 3 important developments:
Great News #1!
Specifically, we heard from TMS centers on both the East Coast and West Coast that they were experiencing a high rate of success in obtaining reimbursement for their patients for TMS services once they were willing to go through the lengthy process of (1) initial Pre-Treatment Authorization Request letter, (2) First Level of Appeal letter, (3) Second Level of Appeal letter, and, sometimes, (4) Third / External Appeal letter.
We hope that this success will begin to spread to the Mountain states from the East and the West Coasts. We are prepared to assist prospective TMS patients with these letters.
Great News #2!
While all this was going on, about three months ago, we learned that one of the ten Medicare Regional Managers (New England states) has agreed that TMS is now a Medicare-covered treatment. Here are a few paragraphs from one of those involved in the time-consuming and arduous process of obtaining Medicare coverage, Linda Carpenter, M.D., of Butler Hospital in Providence, Rhode Island.
““The initial FDA approval of TMS therapy gave hope to many psychiatrists who saw patients whose symptoms were not relieved through traditional medications,”” states Dr. Carpenter, adding that it wasn’t until she began treating patients with TMS that she realized how difficult an obstacle she and her patients would face trying to convincing insurers that this was the best and only line of treatment that could relieve their symptoms.
“Butler was one of the first hospitals in the region to offer TMS therapy three years ago. At the time, Dr. Carpenter was excited for the hope this treatment could bring to patients unable to find symptom relief through medication. What Dr. Carpenter didn’t anticipate was that in addition to providing treatment and care for her patients using TMS, she’d also spend months advocating on their behalf, writing countless appeals letters to insurance companies who were reluctant to pay for the treatment, and representing the patients in legal and community hearings to make the case for coverage of the new treatment.”
““TMS is a game changer for the treatment of depression. And now that Medicare has approved coverage of TMS for the patients who need it, we’re hopeful that other insurers will follow,”” said Dr. Carpenter. ” “Since it was approved by FDA in 2008, ongoing research has consistently shown the benefits of TMS for patients with depression. Medicare’s decision to cover the treatment really reflects how strong the science is, which will in turn help many clinicians and patients realize that TMS is safe and effective.””
Great News #3!
Anthem / BCBS has announced that TMS treatments are a covered service. Anthem/BCBS is one of the larger insurance spinoffs from the original Blue Cross/Blue Shield companies. It writes policies for a 14 state area including Colorado.
Just one year ago, January, 2011, Anthem/BCBS was in a very different place. On their website they wrote:
” This new medical policy considers transcranial magnetic stimulation (TMS) of the brain investigational and not medically necessary for all non-behavioral health indications.”
But, as of August, 2012, they are writing something quite different:
Subject: Transcranial Magnetic Stimulation for Depression and Other Neuropsychiatric Disorders
Policy #: BEH.00002 Current Effective Date: 08/13/2012
Status: Revised Last Review Date: 08/09/2012
Transcranial magnetic stimulation (TMS) of the brain is considered medically necessary for use in an adult who meets the following criteria:
1. Has a confirmed diagnosis of severe major depressive disorder (MDD) (single or recurrent episode);
2. One or more of the following:
• Resistance to treatment as evidenced by a lack of a clinically significant response to 4 trials of psychopharmacologic agents in the current depressive episode from at least 2 different agent classes, at or above the minimum effective dose and duration, and trials of at least 2 evidence-based augmentation therapies; or
• Inability to tolerate psychopharmacologic agents as evidenced by 4 trials of psychopharmacologic agents with distinct side effects; or
• History of response to TMS in a previous depressive episode; or
• Is currently receiving or is a candidate for and has declined electroconvulsive therapy (ECT) and TMS is considered a less invasive treatment option;
This is a listing of the major elements that Anthem will require before automatically acknowledging coverage at the first request. There are a few others, and they can be found with the rest of this posting at : http://www.anthem.com/medicalpolicies/policies/mp_pw_a047769.htm
In my next posting I will explain the steps that those with Anthem coverage can take now to begin treatment as soon as possible. I will also explain how anyone with coverage by any major carrier can help us get the request and appeals process started and moved along quickly. We are increasingly confident in the odds that anyone with coverage from a major carrier who meets basic qualifying criteria for TMS treatment will find their carrier has to acknowledge TMS coverage if they are willing to provide the information we need to crank up our Lean, Mean, Request and Appeals-Writing Machine and get this process started.
Until the next post, if you want information about how to initiate this process of obtaining TMS treatment for yourself or a loved one- go to our website page NEXT STEP, read our directions and complete the medical history form. It is pretty straightforward.
Best Wishes to All,
Joe Hammock, PhD, MA
Clinical Services Director
Southern Colorado TMS Center , LLC