Prior authorization is your insurer's advance approval of a TMS course. Many plans require it before the first session, and the request is normally prepared and submitted by the TMS clinic, using records you and your psychiatrist help assemble. In New York, a state-regulated plan must decide within three business days of receiving the information it needs, and Medicare Advantage and Medicaid plans within seven calendar days.
The steps below show what goes into a strong request and where requests usually stall. Plans revise their rules often, so confirm the current criteria and process with your own plan before anything is submitted.
Does your plan require prior authorization?
Requirements differ by plan, and in one case by whether the clinic is contracted with the plan. This table reflects the documents quoted, read on October 7, 2026.
| Plan | Prior authorization for TMS? | Document quoted |
|---|---|---|
| MetroPlusHealth (Medicaid, Essential Plan, Child Health Plus and other lines) | Required | Provider notice and policy BMD-110, effective November 1, 2025 |
| Fidelis Care (Medicaid, Medicare, Essential Plan, Ambetter) | Required for CPT 90867, 90868 and 90869 | Authorization grid notice, effective October 1, 2024 |
| Cigna / Evernorth | Not required for Evernorth-contracted providers since March 6, 2026; still required for non-contracted providers | Evernorth FAQ PCOMM-2026-021 |
| Medicare Advantage plans | Set by each plan; an approval for a course must stay valid as long as medically necessary | CMS-4201-F (2023 final rule) |
| Original Medicare, Aetna, Optum/UnitedHealthcare, Anthem | Not confirmed in the documents reviewed for this guide | Ask the plan directly |
Waiving prior authorization does not waive the coverage criteria: Cigna's TMS policy still sets them, and out-of-network providers remain subject to medical-necessity review, so the same documentation matters. For a broader look at which plans cover TMS at all, start with Does insurance cover TMS?
Step 1: Confirm benefits and who will submit
Before anything is gathered, the clinic (or you) should confirm three things with the plan: that TMS is a covered benefit, which company manages behavioral health, and whether that company requires prior authorization from in-network and out-of-network providers. Evernorth, for example, notes that some plan documents do not require it even out of network, which is why it says to confirm at the benefit check.
In practice the TMS clinic files the request, because the ordering clinician has to attest to the medical details. Your part is supplying history the clinic cannot see. Ask the clinic who will be your contact for status updates.
Step 2: Build your medication history
This is the part that most often holds things up. Carelon's request form asks for each medication's name, dosage and dates, and Aetna's policy looks for doses at or above the minimal effective dose and durations of eight weeks, plus any augmentation. A simple table like this one, filled in before your consultation, saves a lot of back-and-forth:
| Medication | Highest dose reached | Start and stop dates | Result | Why it stopped |
|---|---|---|---|---|
| Example: sertraline | Your dose | Month and year | Partial or no improvement | Not effective / side effects |
| Example: bupropion | Your dose | Month and year | No improvement | Not effective / side effects |
Pharmacy records, your patient portal and past prescribers can fill gaps. Side effects count: Medicare, Cigna and Optum accept documented intolerance, each with its own conditions. How many trials each plan wants, and what makes a trial "adequate," is covered in how many antidepressants you need to try.
Step 3: Document any psychotherapy
Medicare's LCD L33398 (revision effective August 9, 2026) requires a trial of evidence-based psychotherapy of adequate frequency and duration without significant improvement, documented with standardized rating scales. Cigna's EN0383 (effective March 15, 2026) also requires a psychotherapy trial in the current episode. Aetna's CPB 0469 does not require one for adults, and Optum removed its requirement in 2023.
Useful details are the type of therapy (for example, cognitive behavioral therapy), the therapist's name, roughly how many sessions and over what period, and a short note on how your symptoms changed. A letter from your therapist is often the easiest way to supply this.
Step 4: Record a baseline rating scale
Medicare, Aetna, Cigna and Optum each ask for a validated depression score. Medicare's billing article A57528 lists acceptable scales including the PHQ-9, Beck Depression Inventory, HAM-D, MADRS, QIDS and IDS-SR. Aetna wants the same scale used from start to finish, and Cigna wants scores at the beginning and end of each course. Optum asks for a documented baseline score and a suicide-risk assessment at admission.
You will usually complete the scale at your consultation. If you have older scores from your psychiatrist, bring them, since they show how long symptoms have persisted. Our guide to tracking progress during TMS explains what the scores mean.
Step 5: The psychiatric evaluation and safety screen
The clinician ordering TMS confirms the diagnosis and rules out reasons TMS would be unsafe or unlikely to help. NYS Medicaid asks providers to rule out other causes of depressive symptoms, and MetroPlusHealth's request includes an attestation that acute suicidality, psychotic depression and neurological disorders were ruled out. Carelon's form asks the clinician to attest to exclusions such as a history of mania, recent substance use, psychosis and certain implanted devices. The consultation itself is described in what happens at a TMS consultation.
If you are having thoughts of suicide, tell the clinician; it changes what the right next step is, and it is not a mark against you. If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
Step 6: Submission, and what delays look like
Once the request is filed, the legal clock depends on your type of plan:
- State-regulated commercial plans: a decision within three business days of receiving the necessary information; decisions on continuing an approved service within one business day.
- Medicare Advantage, Medicaid fee-for-service, Medicaid managed care and Child Health Plus: seven calendar days for standard requests and 72 hours for urgent ones, with a specific reason required for any denial, under a federal rule in effect since January 1, 2026.
"Necessary information" is the key phrase. The clock does not really start until the plan has everything it asked for, so the common delays are a missing dose or date, a therapy history with no scale scores, or a request for more records. Some requests are routed to a plan physician: MetroPlusHealth sends requests that do not meet criteria to a behavioral health medical director, and Anthem refers every request for code 90869 to peer review. A short call between your clinician and the plan's reviewer often resolves these.
Step 7: Read the approval carefully
An approval names a number of sessions and a date range. For depression, Aetna allows up to 30 daily sessions plus 6 tapering sessions, Optum's policy uses the same maximum, and Cigna describes an initial course as 30 to 36 treatments. Aetna also covers one re-mapping of your treatment dose per course, and more if you are not responding, without adding sessions. Medicare's billing article sets no fixed cap but says services beyond established parameters may be reviewed.
Check that the approved dates leave room for missed days, and ask what happens if the course runs long. If you switch Medicare Advantage plans mid-course, the new plan must honor an active course for at least 90 days without a new authorization. A later course after a relapse needs a fresh request, judged against the plan's retreatment criteria.
A checklist to hand the clinic
If you collect these before your consultation, most requests can go in within days rather than weeks:
- Your insurance card (front and back) and the name of the company that manages behavioral health benefits.
- A medication table covering the current episode: each drug, the highest dose, start and stop dates, and whether it failed or caused side effects.
- Any augmentation you tried, such as a second medication added to an antidepressant.
- Psychotherapy history: type, therapist, approximate dates and number of sessions, and a letter if you can get one.
- Earlier depression scores, if your psychiatrist or therapist has them.
- Records of any past TMS or ECT, with dates and how you responded. Carelon's form, for example, asks about TMS and ECT in the past three years.
- A list of implants, devices or metal in or near the head, and any history of seizures or head injury.
Keep copies. If the plan later asks for the same information again, or you need to appeal, you will not have to rebuild it.
If the request is denied
A denial is not the end. New York law gives you at least 45 days to file an internal appeal, which must be decided by a clinical peer reviewer who did not make the original decision; expedited appeals are decided within two business days of receiving the necessary information. After that, a state external appeal is available for denials based on medical necessity or experimental status. The full process, with deadlines and fees, is in TMS denied by insurance? How to appeal in New York.
The TMS service page has the practice's current TMS information, and for every other step from first questions to life after treatment, the TMS patient guide. Before any request goes in, confirm the current criteria and process with your plan, since the policies quoted here will be revised.
Sources
- New York Insurance Law Section 4903 (Utilization review determinations). New York State Senate, 2026. nysenate.gov
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet. Centers for Medicare & Medicaid Services, 2024. cms.gov
- Medicaid Update - New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (provider notice). MetroPlusHealth, 2025. metroplus.org
- Fidelis Care Authorization Grids Effective October 1, 2024 (provider notice). Fidelis Care, 2024. fideliscare.org
- TMS prior authorization requirement removal: FAQ for contracted providers (PCOMM-2026-021). Evernorth Behavioral Health, 2026. campaigns.cigna.com
- Repetitive Transcranial Magnetic Stimulation (TMS) Policy and Procedure (BMD-110). MetroPlusHealth, 2025. metroplus.org
- 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) fact sheet. Centers for Medicare & Medicaid Services, 2023. cms.gov
- Repetitive Transcranial Magnetic Stimulation Request Form (commercial contracts). Carelon Behavioral Health, n.d.. carelonbehavioralhealth.com
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal (formerly National Government Services), CMS Medicare Coverage Database, 2026. cms.gov
- Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation (BH803TMS112025). Optum Behavioral Health Solutions, 2026. providerexpress.com
- Billing and Coding: Transcranial Magnetic Stimulation (A57528, version 5). Wellpoint Federal, CMS Medicare Coverage Database, 2026. cms.gov
- New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (NYS Medicaid Update, Vol. 41 No. 7). New York State Department of Health, 2025. healthweb-back.health.ny.gov
- MCG Care Guidelines 28th edition (Anthem New York provider news). Anthem Blue Cross and Blue Shield (New York), 2024. providernews.anthem.com
- New York Insurance Law Section 4904 (Appeal of adverse determinations). New York State Senate, 2026. nysenate.gov
- File an External Appeal. New York State Department of Financial Services, n.d.. dfs.ny.gov
FAQs
Who submits the TMS prior authorization, me or the clinic?
Usually the TMS clinic, because the ordering clinician has to attest to your diagnosis and safety screening. You help by supplying your medication and therapy history and any older rating-scale scores.
Can I start TMS while the authorization is pending?
You can, but sessions given before approval may not be paid if the plan requires prior authorization. Ask the clinic and the plan in writing before starting.
What if my approval runs out before I finish?
Ask the clinic to request an extension before the end date. In New York, decisions on continuing an approved service by state-regulated plans are due within one business day of receiving the necessary information.
Do I need a new authorization if I change insurance during treatment?
Usually yes. One exception: if you switch between Medicare Advantage coordinated care plans, the new plan must honor an active course for at least 90 days.
Does prior authorization guarantee payment?
No. It confirms medical necessity, but your deductible, copay or coinsurance still apply, and plans can review claims that fall outside the approved sessions or dates.
