Member Forum Archive (Pre-Oct 2024)

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Looking for MagVenture Cool B70 - Submitted by Jack Castro on Mon, 08/19/2024 - 06:53

Hello everyone, I wanted to ask- my MagVenture Cool B70 coil is leaking fluid and tech support is not able to help and say only option is to purchase a new one. I was wondering if anyone here is looking to sell their coil. Please let text me at 646 755 5476 Jack Castro, MD

Nearly Paid off Brainsway 104 Devices For Sale Submitted by Piper Buersmeyer on Thu, 05/09/2024 - 12:35

I have multiple Brainsway 104 systems that are nearly paid off and are available for a fortunate TMS provider! Feel free to reach out to me via my cell phone 360-610-0545 or piper@tms-nw.com. Thank you!

Job opportunity - Psychiatrist Submitted by Kevin Kinback on Thu, 04/25/2024 - 18:38

Advanced TMS Center in Ladera Ranch, coastal Orange County, CA, seeks board-eligible or certified psychiatrists.

About Coastal South Orange County, CA: Busy insurance based practice located 5 miles from the Pacific Ocean. Weather is clear nearly every day, mild winters, outstanding life-work balance. Only 1 hour drive to Los Angeles, San Diego, Palm springs, deserts and mountains. We have water sports, hiking, snow skiing, museums, Hollywood, concerts, the entire Cal State and Univ. California educational system, excellent public and private high schools, etc.

About Advanced TMS Center: Our group has 11 support staff and currently 7 psychiatrists and psychologists treating children, adults and geriatrics. We seek several more psychiatrists, preferably working onsite, but telehealth is ok.

Our EMR is in the top 5 nationally, with integrated EKG's, labs orders/results, patient and peer portals, telehealth, messaging, etc. We give extensive training in both EMR, HIPAA and offer mentoring to new grads. We do weekly peer-review, case discussion meetings for clinicians, and staff admin meeetings.

We can do 1099, or W2, with extensive benefits including: paid time off, sick time, worker's comp insurance, medical & disability insurance, paid license and DEA, loan repayment allowance, retention bonuses, IRA/profit sharing, and most importantly ownership/partnership options. You can actually own part of the practice going forward and build equity, as you participate in administrative decisions. Base salary is at least 280,000, plus productivity bonus, and with benefits, exceeds $375,000 in value.

If you treat TMS patients, your take-home pay would easily exceed $350,000 to $400,000.

Our new first-class office has extensive views, with 3,000 SF of space customized for psychiatry.

See our job posting here: https://advancedtmscenter.com/join-our-team-adolescent-adult-psychiatri…

Please fax your CV to 949-768-2980 and call us at 949-768-2988. Meanwhile check out our website at: AdvancedTMSCenter.com

Kevin Kinback MD

Advanced TMS Center, Ladera Ranch, CA

NeuroStar TMS in like new condition for sale - Submitted by Justin Lapollo on Tue, 08/29/2023 - 08:35

We have a 2022 like new NeuroStar machine that comes with D tect neuromapping assist that we are looking to sell. Price negotiable. Please contact Bethanie Wilson (Practice Manager for Maryville Psychiatry) at 412-354-9847 or maryvillepsychiatry@gmail.com for any interested parties.

Neurostar 2018 with -Submitted by Sanjay S Chandragiri on Fri, 07/07/2023 - 12:23

2018 Neurostar system with Dash protocol for sale. in excellent condition. price negotiable.
please contact me at
chandragiri2@gmail.com
5706508711

psychiatrist needed - Submitted by Mark Waynik on Tue, 08/22/2023 - 10:25

looking for a full time psychiatrist in Fairfield County. We offer TMS.

Clinical Discussions

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rTMS for neuropathic pain protocol - Submitted by Benjamin Williamson on Tue, 11/21/2023 - 14:19

Is anyone treating neuropathic pain at M1 with a figure-of-8 coil? If so, what protocol are you using? Are you treating at the hotspot or some other location? How are you orienting the treatment coil? Thank you!

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Submitted by Santharam Yadati on Tue, 12/12/2023 - 11:13

i have the same question

Is anyone treating chronic pain and what is the protocol M1 location
Please

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Submitted by Santharam Yadati on Tue, 12/12/2023 - 11:13-

i have the same question
Is anyone treating chronic pain and what is the protocol M1 location
Please

------------------------

Submitted by Lane M Cook on Mon, 09/30/2024 - 13:48

So the MagVenture clearance is to put the coil over the painful spot and treat at 0.5Hz (1 stim every 2 seconds), very short protocol. Did one severe neuropathy that 2 reputable pain clinics couldn't help and neither could I. I also treated a woman who had a total ankle revision and developed Complex Regional Pain Syndrome Type 1 (complete with what she called her "Hobbit foot" that grew hair) with significant pain. She wound up reducing her pain from a 6 down to 1 and got off gabapentin. MagVenture makes several coils designed for areas like the back. Go to their website and under Patients go to Pain therapy and there's info and vids.

Braids - Submitted by Daniel Boyd on Mon, 04/22/2024 - 06:44

I fear braids might prevent my patient from getting an adequate response to TMS. Any advice? Or experience with successes or failures with braids?

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Submitted by Lane M Cook on Thu, 04/25/2024 - 19:55

We had an African-American woman with braids so thick we couldn't elicit a motor threshold. I emailed Mark George who said they had the same issues with some of their patients and the only solution was to take down the braids which can be quite expensive to style.
Hypoparathyroidism and TMS - Submitted by Megan Foster on Thu, 09/26/2024 - 09:24

I have a patient with post-surgical hypoparathyroidism after complete removal in teen years. Calcium/phos levels well managed prior to TMS. She had a drop in serum calcium after three days of TMS and is asking if it could be related. I cannot find any literature that supports this possibility, but I want to reach out to others to find out if it is theoretical possibility given that she does not have the mechanism to moderate these levels.

I'm reaching, I'm sure, but I don't want to negate something without discussing with others.

Regards,
Megan Foster, ARNP

Post- TMS series follow up - Submitted by Lisa Young on Wed, 04/24/2024 - 13:48

I wondered if anyone has templates for RN follow ups after TMS? In other words what I'm looking for are templates that practices are having clinic RN's are using to chat with patients at specific intervals after TMS to assess response and need for rescue treatments.

PTSD rTMS protocol - Submitted by Corey Scott on Tue, 03/12/2024 - 09:37

Previously I had been using a Brainsway device with a 20 hz protocol for a few PTSD clients with a pre-read third person script of the triggering event in conjunction with a therapist. I now only use Neurostar and would like to program a custom protocol Has anyone been doing any certain rTMS protocols they would be willing to share that patients have had success with other than just the standard MDD protocol on machine.

Approved TMS Protocols for MDD - Submitted by Naveed Riaz Khokhar on Fri, 11/18/2022 - 07:24

Hi,

I am new to TMS and developing service in my clinic. I was wondering if there is any good source to study FDA approved treatment protocols for depression including SAINT. Will also like to know the protocols using deeper coils.

Thank you,

Naveed.

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Submitted by Gregory Job on Mon, 01/29/2024 - 06:59

This is a frequently asked questions. Most of the questions in the form seem to go unanswered. Wonder if CTMSS is really relevant anymore

rTMS safe for use in patient with implantable loop recorder? - Submitted by Erin Jewell Burks on Thu, 01/25/2024 - 08:09

Patient meets criteria for rTMS for MDD, but had loop recorder placed in chest area in December 2023 for 3 years to assess cardiac rhythms. Wanting to confirm that this is safe to proceed?

Theta Burst statement - Submitted by Rick Trautner on Wed, 02/10/2021 - 08:59

On behalf of the Clinical Standards Committee, Saydra Wilson and I are interested to know if you are using Theta Burst in your practice. If so, have you had any problems with insurance companies and authorization for that? Finally, have you had a chance to review the CTMSS statement on Theta Burst (pasted below) and if so, has it been helpful or not? Thank you. 

 Theta Burst Statement

Intermittent Theta Burst Stimulation (iTBS) is a TMS protocol that was recently cleared by the FDA for depression based largely on a non-inferiority study comparing it to standard HF left prefrontal cortex (PFC) treatment. At this time, the clear preponderance of evidence both for efficacy and safety supports the use of HF left PFC in the treatment of MDD and therefore it should be considered the standard approach. iTBS is a promising approach that has a role in TMS treatment and may be used when, in the opinion of the treating TMS physician, circumstances justify its use as an alternate to the standard approach.

Submitted by Stephen Rush on Wed, 10/26/2022 - 11:01

--------------------------------------

We have a neurostar machine with the theta burst update (which they call TouchStar).  For each evaluation and prior-authorization I now submit a dolcumentation requesting both standard TMS protocol OR  iTBS protocol, listing the details of each for the payor source.  Thus far I have recieved approvals for all of those patients. 

Stephen,

Interesting approach. I have a TMS practice in the Austin, Texas area. I utilize iTBS when I can with my patients. Would you share a copy of what you submit to the insurance companies a you described above with the rTMS OR iTBS clause? If so, my email is below.

I would greatly appreciate it.

-Take care Brian Earthman (brian@eearth5.com)

rescue/re-treatment TMS recommended length - Submitted by Kari Case Heistand on Tue, 06/13/2023 - 17:07

Have patient who had very successful TMS with resolution of depression ending in 2/2023. She is calling and noting depression returning. I see research citing anywhere from 2 to 6 weeks of treatment for a re-treatment or rescue course of treatment, but cannot find specific length recommendations. Are any of you aware of any specific recommendations regarding length of re-treatment? Is taper handled differently? Thank you, KH

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Submitted by Lisa Bailey on Tue, 09/12/2023 - 12:31

I would like to expand on this question. I am currently re-treating a patient for the third time (depression, LDLPFC) and she is again responding well, and quickly. I want to advocate to her insurance for "preservation", "maintenance", whatever were are calling it, but I really am unsure what protocol to recommend. I got an email from the TMS society back in March about an official statement on preservation TMS but that link no longer works. Any advice/clinical recommendations etc is welcome. thank you

Hi all,

For those who like me google this bank wondering for directions for when to retreat, I found this interesting paper that may help while debating clinical efficacy as well as navigating insurance coverage request.
https://doi.org/10.1016/j.jad.2021.09.040
Systematic review of preservation TMS that includes continuation, maintenance, relapse-prevention, and rescue TMS
Author links open overlay panelSaydra Wilson a, Paul E. Croarkin b, Scott T. Aaronson c, Linda L. Carpenter d, Michelle Cochran e, Debra J. Stultz f, F. Andrew Kozel g

Anxiety/Agitation/Insomnia - Submitted by Eric A. Robbins on Wed, 10/18/2023 - 19:59

Hello everyone. Need help for a patient who reached out to me after 6 months of receiving TMS complaining of persistent anxiety/agitation/insomnia. He received a course of left sided rTMS and right sided iTBS. Would like to know if anyone has had a similar patient experience or to offer any suggestions or thoughts on how to help this patient. TIA for any and all help.

SAINT Inpatient - Submitted by Naveed Riaz Khokhar on Wed, 09/27/2023 - 19:52

Hi, I work on inpatient and we started using SAINT protocol on inpatient unit. Sometimes there are patients who do not want to have all 10 treatments in a day. Is there any minimum number of treatments a day which a patient must have?

SAINT protocol - Submitted by Jessica Rigas on Mon, 01/10/2022 - 07:39

Is anyone using the SAINT protocol (TEN 9 minute sessions per day for 5 days)? I was told that it is reccommended to not do this protocol until it is FDA cleared?

Thank you!

-------------------------------

We've treated one patient with success following the SAINT protocol. Prior authorization was approved by insurance company before administering. Patient achieved remission. 

The prior authorization document had both protocols listed. We used the same clinical documentation that would be used for the standard tms protocol (hx medication trials, therapy trials, side effects from medications, etc). I will say that although insurance approved prior auth, claims are processing very slowly due to billing more than one tms session/day. Representatives have been very helpful.

We're not switching all our patients to this protocol, our clinic tried one patient to see how it could flow in the clinic from a clinical, operational, and billing stance.

Do you mind sharing which insurance carrier it was that approved and where you are located?  We haven't seen any policies or PA forms including the SAINT protocol as an option in Texas yet but are asking our insurance reps.  Wondering if it is available only regionally.  Also, can you provide feedback on how it went in your office.  We are getting a lot of requests from patients but are not sure how it would work from a flow perspective, not to mention billing, etc.

I see you called this a SAINT protocol, and I am curious if you did the Functional Connectivity targeting with your treatment, and if so how and where?  What was the circumstance whereby you offered the treatment?  Had the patient failed a regular course of care? or was there other reasoning for offering it.  I am also curious if the patient remained in remission following the treatment or if they relapsed within the following few weeks?

 I heard Anthem was paying for an Accelerated protocols, 10 - iTBS (1800 put 90% of the patient's MT separated by an hour, for 5 days but only paying for one treatment per day.  Did the insurance company you worked with actually pay for 10 treatments in one day?  No functional connectivity payments that I have heard that have been covered.  

The society likely needs to collect information via a Research workgroup on those prescribers who are treating with 10X per day iTBS (1800 pulses) at 90% of the patient's MT separated by an hour, for 5 days and see if clinical practice can collect the durability data we all need long term.  

Using MEP/EMG (surface muscle sensors) to determine MT - Submitted by Kent Comeau on Fri, 09/15/2023 - 08:31

Has anyone used an electromyograph sensor on the thumb/finger to find the motor threshold ? Some of our patients have had only vary small, subtle or even invisible thumb-twitches and I am wondering if using a portable EMG device (like this: https://ca.robotshop.com/products/electromyography-emg-sensor?gclid=Cjw…) would be useful or even feasible to use in a private practice.

Does anyone have experience with this tech or method?

TMS with Implanted eye stents and OFC location - Submitted by John L. Fleming on Sat, 09/02/2023 - 08:31

Until recently I was unaware that eye stents can be implanted in the trabecular structure of the eye during cataract surgery when open angle glaucoma is present. These eye stents are small titanium tubes coated with heparin. Commonly known as iStents. Because titanium does heat up under magnetic stimulation, I was curious about the possibility of damage during TMS treatment. Information from the manufacturer Glaukos https://www.glaukos.com/dfu-mri-information/
however is reassuring, provided duration of magnetic pulse limits are observed. To me as always distance degrades magnetic field strength it would seem to me that until information emerges, coil location for OFC Orbital Frontal treatment should be avoided.

John Fleming, MD, Fellow, CTMSSS

TMS - Submitted by John L. Fleming on Sat, 09/02/2023 - 08:24

ngs.

Antiepileptics during TMS - Submitted by Naveed Riaz Khokhar on Thu, 08/17/2023 - 11:56

Any guidelines if AEDs, specially when used for mood disorder, should be weaned off prior to TMS and motor thresholding?

PERMANENT MAKEUP - Submitted by Shannon Johnson on Thu, 06/29/2023 - 16:25

I was going to start a patient on TMS and she checked on the consent form that she has permanent makeup: eyebrows, eyeliner and lipstick. Has anyone done TMS on a person that had this much permanent makeup? what was the outcome, would doing TMS on someone with permanent makeup depend on how long ago the makeup was placed?

TMS with implanted hypoglossal nerve stimulator - Submitted by Roberta M Richardson on Wed, 06/14/2023 - 14:12

Hello, all-- wanted to share my experience regarding this new technology that we all will be seeing more of soon.

I recently evaluated a patient for a second course of TMS for highly treatment resistant depression. He had a very good response to the first course. In the interim he had an Inspire hypoglossal nerve stimulator implanted, for obstructive sleep apnea.
I began digging to see about the safety of TMS with this implant. I learned that the leads do contain some ferromagnetic material, and that the device manufacturer states TMS is therefore not safe. However, the manufacturer proudly publicizes that its newer devices ARE safe for MRI scans, as long as certain (pretty standard) parameters are met. When I asked the representative who answers questions for physicians about the Inspire device why the discrepancy, he told me that TMS utilizes magnets that are measured in kiloTeslas, compared to mere Teslas for MRIs (!). He was apparently not aware that the strongest magnet in the world is a mere 44 T in strength. Anyway, after going up the chain at the Inspire company, I learned that their position is based on an FDA document of guidelines for device manufacturers regarding TMS, from 2011, which got its information from the TMS safety guidelines assembled by an expert consensus group from the IFCN (international federation of clinical neurophysiologists.) in 2009.

The thing is, these safety guidelines were updated by the same group in 2021, and they now state that TMS can safely be administered in the presence of vagus nerve stimulators. The hypoglossal nerve stimulator is so similar, that it is quite reasonable to extrapolate, especially as you look at the very detailed discussion of the topic in the publication.
Here is a link to that paper. The relevant section is 3.2 (credit to Dr Aron Tendler for sending me this reference.)

https://www.sciencedirect.com/science/article/pii/S1388245720305149?via…

Of course the patient's insurance carrier is not going to authorize, but we will go through the steps and appeal, because this patient has very few other options.

I wonder if there is any movement within the CTMSS to ask the FDA to update their guidelines?

Patient with unknown metal non removable earrings - Submitted by Robbie Bahl on Thu, 03/09/2023 - 13:20

Hi there,

I was wondering if anyone has run into a patient with gaged metal earrings before? This type of body jewelry can only be removed professionally by a piercer. The patient does not know what kind of metal her earrings are made of but had them removed before getting an MRI once. I'm leaning toward asking them to do that as well but was wondering if there was any way to figure out if the material is TMS safe or not before making a patient that relies on public transportation make another appointment just to get her earrings taken out. They put a kitchen magnet to the earring and it didn't seem to be magnetic, but that's a significantly weaker magnet. Any advice?

-----------------------------------

Dr. Bahl,

I use a figure 8 coil, MyCloud TMS system and have had patients with those type of earrings. The "laser like magnetic pulse" only goes about two inches in thru the skull and  LDLPFC, so in theory the ear lobe is greater than 2 inches away from the coil and pulse. I educate the patient that the risk is there, but I have treated various patients without any problems or side effects, but at the end of the day it is up to them. This is documented in the consent form and staff assess during treatment for any complaints. 

Alfredo H. Arellano

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Submitted by Lane M Cook on Mon, 03/13/2023 - 17:55

We use a magnet to test it. Stainless steel paradoxically is not ferromagnetic. If the magnet doesn't pull it, it's safe. Just tried on a tongue piercing, was stainless steel. 
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Submitted by Roberta M Richardson on Wed, 06/14/2023 - 13:42
Serious question: what is the worst that could happen, if the earrings turned out to have some ferromagnetic material? My understanding is that there can be two effects: heating and movement. This could be disastrous for something implanted internally, but for earrings, it seems to me the worst would be that the patient would feel heat, and if it is significant, can tell the operator to stop the machine. And, the earrings could move a little. I'm not familiar with the kind of earrings you are asking about. Is there some room for movement, as with most piercings?
I also don't know: could this cause any harm to the TMS machine?
Tinnitus - Submitted by Ali Elahi on Mon, 05/10/2021 - 14:31

I have been using various protocols for treatment of subjective tinnitus with marginal benefits.  Does anyone feel they have been able to find an effective protocol for tinnitus?

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Submitted by Abigail Moore on Sun, 09/26/2021 - 13:53

I have been trying to figure out coil placement and protocol and have not been able to find a place to start even.  I will be happy to share my results as soon as I have some!  Do you have a reference for whatever you have tried?  Or can you let me know the effect of whatever you have tried?

Thank you so much!

-----------------------------

Submitted by Justine Sever Chilelli on Fri, 01/14/2022 - 05:54

What protocol are you using? We have one patient very interested in this. Any advice is greatly appreciated.

Submitted by Martha St John on Thu, 06/30/2022 - 07:04

In reply to  by Justine Sever Chilelli

Wondering if either of you has any new information to share on your experiences with treating tinnitus.  I have had a prospective patient approach me about TMS for tinnitus but I haven't treated for tinnitus before and the brief literature search I did didn't suggest that results were very robust, nor durable.  It also looks like there is no clear consensus on a protocol.  Any information would help me guide this patient! Thanks!

Submitted by Christopher Slack on Wed, 01/11/2023 - 19:11

we are looking to start TMS for tinnitus. Previously i have treated aud hns at the L T-PJ with some success using the 10 -20 eeg system to locate the spot but it is a fiddly excercise.   Has anyone got a better way of locating the site?   Chris Slack

TMS for negative symptom and psychosis in Schizoaffective disorder - Submitted by Sanjay K Nigam on Tue, 11/22/2022 - 10:40

I have 41 year ol white male with schizoaffective disorder, Currently Stable. He has h/o sucidal attempt, past cocaine use during psychosis. He wanted to know if we can do TMS for his negative symptoms or psychosis. I am thinking both will be targeted differently. I would like to ask if any one has treated psychosis with rTMS or negative symptoms. 

if yes than

  1. what protocol have you used for psychosis? MT location, number of sessions etc
  2. what protocol are you using for negative symptoms?

have you used brainsway or neurostar

Thanks

 Sanjay Nigam

MT Estimation issues - Submitted by Gregory Job on Tue, 11/15/2022 - 06:07

Recently had patient, middle aged female on Buproipion and Mirtazapine. Went all the way upto 100% on a Magventure machine. Couldnt elicit and hand or even arm movement.

What would you do next

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Submitted by Sanjay K Nigam on Sat, 11/19/2022 - 13:12

May try to elicit MT Threshold  on rt side, than use the readings on left side as MT Threshold and Mt Location will be mirrored

TMS and Ketamine - Submitted by Lisa Bailey on Mon, 12/20/2021 - 10:46

Hello,  I have been referred a 27 y/o woman for tx resistant depression for TMS. She has chronic pain and headaches (including migraine) and is taking oral Ketamine daily for pain. She has established with neurology and they suspect rebound headache (pain meds are coming from a pain clinic).  I know there are some ketamine + TMS protocols for depression but  I have no experience prescribing Ketamine and would appreciate any guidance in administering TMS while Ketamine is on board.  I have also had some pts have their headaches worsen with TMS so I am concerned TMS will confound her current problem of uncontrolled headaches.  thank you

-------------------------------

I would first look her Controlled Substances Medication History through your state's Prescription Monitoring Program and find out what are all of the controlled substances she is being prescribed and who is prescribing them. Based on limited information provided, I would not take over the prescribing of Ketamine since it is for pain and her Pain MD has an agreement with her that all controlled substances are recorded and/or prescribed by him/her. I do not think Ketamine is available PO (only IV or nasal ). Ketamine IV is used and effective for severe depression with suicide ideations, but not long lasting nor FDA approved for Depression. Spravato (esketamine) intranasal inhaler is approved for MDD, but administered in a specialty clinic. I would tell the patient that you can offer her TMS for her Treatment Resistant Depression, but also keep in mind what all controlled substances she is taking and assess whether there is an underlying substance use disorder. The FDA 19 minute protocol over LDLPFC would be the protocol to target her depression. If she is unable to tolerate it, then you can use MDD protocol 1Hz, 110% to RDLPFC (https://jamanetwork.com/journals/jamapsychiatry/fullarticle/204901) (https://www.sciencedirect.com/science/article/abs/pii/S0278584605002794?via%3Dihub). Only drawback, this is not FDA approved.  Interesting patient. Hope it helps. 

Submitted by Lisa Bailey on Mon, 12/20/2021 - 13:21

In reply to  by Alfredo Herrera Arellano

thank you Alfredo.  To clarify:  I do not prescribe my TMS pts any psych meds.  They are referred to me (the TMS provider in my organization) from their treating psychiatrist or NP. So I would not take over the Ketamine, nor anything else.  And yes, she is taking PO ketamine.  Is there any contraindication to giving TMS to a pt on daily ketamine, assuming she is otherwise a candidate?

I personally, like to know all the meds the patient is on and why they are on them, in order to determine any possible interaction with rTMS.  Ketamine affects resting and active motor threshold & cortical excitability  as do other controlled substances, plus most studies have been done with IV Ketamine for the treatment of depression, not with PO Ketamine for pain control. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2342642/) (https://www.cell.com/heliyon/fulltext/S2405-8440(19)35847-5). I have treated patients with TMS and Spravato, but never with IV or PO Ketamine, so I cannot give you an opinion. Spravato and TMS combined has been very effective and with no side effects. Do you have a list of all her meds controlled and non-controlled that patient is taking? This might help clarify the case.

Submitted by Alfredo Herrera Arellano on Mon, 12/20/2021 - 13:42

In reply to  by Lisa Bailey

I personally, like to know all the meds the patient is on and why they are on them, in order to determine any possible interaction with rTMS.  Ketamine affects resting and active motor threshold & cortical excitability  as do other controlled substances, plus most studies have been done with IV Ketamine for the treatment of depression, not with PO Ketamine for pain control. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2342642/) (https://www.cell.com/heliyon/fulltext/S2405-8440(19)35847-5). I have treated patients with TMS and Spravato, but never with IV or PO Ketamine, so I cannot give you an opinion. Spravato and TMS combined has been very effective and with no side effects. Do you have a list of all her meds controlled and non-controlled that patient is taking? This might help clarify the case.

I DO collect all that info, I just don't manage the meds.  She takes acyclovir, buspar, ketamine, metaclopramide, mirtazepine, odansetron, prazosin, pregabalin, topiramate, lamictal, trazodone and PRNS of methocarbamol, rizatriptan.  Yes, it's a bit of a mess and I would hope TMS would be a non medication alternative for this person who chases her pain with doctor visits and pills.  I work in a public health setting so most of my referrals are medically complicated.  That's not a problem.  I've just never seen ketamine as part of an ongoing medication regimen before.

Submitted by Alfredo Herrera Arellano on Mon, 12/20/2021 - 15:23

In reply to  by Lisa Bailey

That is quite a combination. I struggle to get other providers to buy-in to reducing or discontinuing medications, even after they start and improve on TMS, but since they are in the hands of another provider, I let the patient know I can only do so much as a consultant. She is on alot of sedating medications to include Ketamine. If she wants to be off some of these meds and her providers follow your recommendations, she can improve with rTMS. Good luck. 

Submitted by Stephen Rush on Wed, 10/26/2022 - 10:54

We offer both ketamine/esketamine and TMS in our practice and have had a few patients getting both ketamine (intranasal) and undergoing TMS (we actually had a PCORI grant to study this combination some time ago).  The TMS procedure has, across the board, been more tolerable because of some sustained analgesia provided by the ketamine/esketamine.  There is no contraindication in this situation and we have, for each patient, proceded with normal TMS protocol.

Clinical TMS Society

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Which machine to purchase? - Submitted by Mark Waynik on Sun, 08/20/2023 - 09:38

Am changing from Neurostar. Have evaluated other companies , but am not sure which to purchase. Has anyone had any resistance by patients due to the appearance and feel of the Brainsway?

Definitions - Submitted by James Taggart on Mon, 07/24/2023 - 09:19

What definitions is the clinical TMS society using for response and remission in treating TRD with TMS?

TMS DURING PREGNANCY - Martha B Koo on Tue, 10/26/2021 - 21:59

The research committee would like to identify providers who have treated pregnant women with TMS.  If you are willing to identify yourself, can you post your name, the TMS device you use, and any objective rating scales you track? Thank you.

TMS ADVERSE EVENTS - Martha B Koo on Fri, 09/03/2021 - 15:20

Hello CTMSS Members,

This Forum is created by the Research Committee in an ongoing effort to gain information about adverse events related to the clinical application of TMS. Please post AE's on this forum. Thank you. The CTMSS Research Committee.

Devices

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Looking for MagVenture Coil B70 - Submitted by Jack Castro on Mon, 08/19/2024 - 07:00

Hello everyone, I wanted to ask- my MagVenture Cool B70 coil is leaking fluid and tech support is not able to help and say only option is to purchase a new one. I was wondering if anyone here is looking to sell their coil. Please let text me at 646 755 5476 Jack Castro, MD

------------------------------------------

Submitted by Lane M Cook on Thu, 09/05/2024 - 17:53

I have a MagVenture stimulator and we always buy the yearly maintenance subscription which actually saves you money on the coils which do have to be replaced. I spoke with Patrick Donahue at MagVenture when he was doing our yearly testing, maintenance and replace our MT coil. He said when you drop a coil the plastic cover will crack and there is no repair, you have to replace it. I can't imagine now that MagVenture is the number 1 selling TMS device in the U.S. that anyone would have a spare coil to sell you. Sorry.

Device disposal - Martha St John on Wed, 03/29/2023 - 14:13

I have a Neurostar purchased in 2012 that I have not used in about 3 or more years. I let the service agreement go and do not plan to use it again. It is functional but needs some maintenance. I don't imagine anyone would purchase it and it is occupying expensive real estate in my office. Does anyone know the best way and most economical way to dispose of it?

Education

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Anxiety Protocol - Willie Lynch on Wed, 11/17/2021 - 19:28

Has anyone used TMS for anxiety. If you have had success, what is the protocol that ahs been most successful. I have learned that it is on the right side at 1Hz every one second. What I am not sure of is what is the most recommended number of pulses per session? Thank you for the information. 

TMS DURING PREGNANCY - Submitted by Martha B Koo on Tue, 10/26/2021 - 21:54

The research committee would like to identify providers who have treated pregnant women with TMS.  If you are willing to identify yourself, can you post your name, the TMS device you use, and any objective rating scales you track? Thank you.

--------------------

I have administered Tms therapy on a pregnant patient. NeuroStar device was used. Patient had stopped medications during pregnancy. Tms Therapy was effective and patient achieved remission. Rating scales that were used included: HAM-D, GAD-7 and PHQ-9.

General Discussion

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Facebook and other forums with scary stories - Submitted by Lane M Cook on Mon, 09/30/2024 - 13:41

So there's a couple of Facebook private groups, one I joined, Transcranial Magnetic Stimulation TMS Support Group. I joined a couple of years ago and it was pretty sane but is becoming like other groups with people posting outrageous side effects from TMS. I wish members would join and monitor them. I just posted a long post in that group.

This is from a 2022 study that gathered a huge amount of data about the safety of TMS. A total of 53 randomized sham-controlled trials with 3,273 participants were included. With meds you test the medication versus an inert “sugar pill” placebo. With devices, you have to have a sham device that looks and feels like the device. MagVenture has a 2-sided coil with an active treating coil on one side and the sham on the other that will knock and feel like the real deal but no magnetic pulsing. The larger the number of studies with multiple participants in them the more reliable. In the first part 45 studies had an adverse event (side effect) that led to dropouts, both mild and serious. 1.3 (the odds ratio) times as many patients dropped out on active vs sham TMS, was not significantly significant (requires a P value < .05 ( or 5%). Seizure was not statistically significant even though the odds ratio looked high but was due to 2 patients out of 127; one happened in a Brainsway deep TMS device which has a higher but still insignificant risk of seizure and the individual was also withdrawing from alcohol, a known risk factor. The second seizure happened 4 days after the last treatment so was highly unlikely due to TMS.
As to the less serious side effects, the 3 most common and the only statistically significant adverse events were the “usual suspects” of headache, discomfort at the stimulation site, and pain at the stimulation site. The others were not statistically significant in incidence compared to sham. Yes, you can get dizziness, anxiety, and insomnia from virtually all psychiatric meds as well as TMS but were not statistically significant. Neither were tinnitus, muscle twitching and switch to hypomania.
Most of the very unusual reports in forum don’t fit with the experience by clinics and published literature on TMS. Reference: Wei-Li Wang, Shen-Yi Wang, Hao-Yuan Hung, Mu-Hong Chen, Chi-Hung Juan, Cheng-Ta Li, Safety of transcranial magnetic stimulation in unipolar depression: A systematic review and meta-analysis of randomized-controlled trials, Journal of Affective Disorders, Volume 301, 2022, Pages 400-425 (this is behind a paywall, have to have academic access or subscription for the entire article). I posted figures 4A and 4B and explained it.
There's also comments about providers discontinuing treatment after 10-15 sessions due to no improvement.

Any members in Alaska? - Submitted by Jeremy Allen Jensen on Fri, 08/16/2024 - 18:45

I'm just curious if there are any other members in Alaska.

Transcranial Magnetic Stimulation TMS Support Facebook Group - Submitted by Lane M Cook on Thu, 04/25/2024 - 20:15

So I found this group on FB a couple of years ago. I joined and some of their posts pop up in my feed. There are outrageous amounts of misinformation about unheard of severe side effects from TMS I have a hard time believing. What I do believe is there are many technicians out there who don't have a clue how to perform TMS, resulting in intense pain, muscle twitching, not building up to 120% MT in a few days, etc. A new group was formed (I forget their name) to counteract all the bad press and focuses on the positive. I also see terrible advice about taking or stopping meds by the psychiatrists during TMS.

Practice Management

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Joint Commission - Submitted by Babu Gupta on Wed, 09/18/2024 - 06:43

Anybody here went through Joint Commission certification for their practice? Any advice on what they may look for in a tms practice?

Medicare TMS Requirement - Submitted by Alfredo Herrera Arellano on Tue, 07/02/2024 - 07:29

Medicare used to have a requirement that the MD/DO had to be present or provide direct supervision (be within same building) throughout the course of TMS therapy?

In reviewing the latest policy, I do not see this. Does anyone have any knowledge or experience on CMS requirements? The policy reads:

TMS of the brain for severe MDD, single or recurrent episode, is considered medically reasonable and necessary for up to six weeks3,5,6,16-19 when the following criteria are met:

The patient has a confirmed diagnosis of severe MDD as defined by the current DSM.
AND
The patient has demonstrated a failure of one or more trials of a pharmacological medication and/or demonstrates an intolerance to psychopharmacologic medications as defined in the definition section above.
AND
The order for TMS procedure is written by a psychiatrist (MD or DO), who has examined the patient face to face and reviewed the record.

Thanks,

Alfredo Arellano

-----------------------------------

Submitted by Robert Olsen on Thu, 07/25/2024 - 12:33

I just had a meeting with Optum medical director and clinic liasion for the west coast, and was told that they maintain the need for a MD or DO be in physically in the office (but not the treatment room) for application of tms.

However, their policy heavily references the unrevised tms guidelines. Is anyone working on a response to Optum's dated policy?

Are people limiting Optum as a payer since no one of us can be in multiple places throughout the day?

Submitted by Scarlett Mulligan on Sat, 09/14/2024 - 20:20

As I understand it: CMS is comprised of 12 jurisdictions. Each jurisdiction has a Medicare Administrative Contractor (MAC) - 7 total as a few manage two jurisdictions. Each MAC has a Local Coverage Determination (LCD). There are two LCDs that do not require the presence of a psychiatrist on site / "in the area."

Submitted by Babu Gupta on Wed, 09/18/2024 - 06:03

Are there any other insurances that require physician to be in the area?

What do most practices do? I am usually in the area of treatment, but sometimes I do go to nursing homes or hospitals during the day.

WANTED: TMS websites and TMS Facebook pages etc. worldwide-let's make a list - Submitted by Mark Xuereb on Sun, 06/14/2020 - 02:43

Hi all,

I'm compiling a directory of TMS websites and TMS FB pages as part of a research project I'm doing for future TMS meetings etc. May I please ask you all to insert your TMS URL and TMS FB page in your replies please? If you use Twitter, Instagram etc. please do include them.

You can also send an email if you wish (info@tmsmalta.com). 

Besides, information sharing, this will also enhance google search algorhythms for the public to find each one of us.

Ours are:

www.tmsmalta.com

Facebook & Instagram: TMS Malta & Gozo

Thanks

Mark

----------------------------

Thanks for doing this. My website is suburbanbhs.com

Mazhar Golewale MD

Thanks for compiling. Here's the website for the practice I work at in Louisville area: https://tmsglobalnetwork.com/

Best,

Dani

----------------------------

Here is my website, FB and IG pages.

www.aapsychaitry.com

Instagram: aapsychelpaso

Submitted by Farooq Amin on Tue, 08/31/2021 - 09:53

www.excelpsychiatricconsultation.com

Submitted by Mark Xuereb on Sun, 09/05/2021 - 12:30

Thanks TMS family. Let's have more coming please.

www.dauntlesspsychiatry.com

Fayetteville, AR 72703

Thank You!!

Submitted by Mark Xuereb on Sat, 06/25/2022 - 06:18

Hi all.

Let's keep it going....any more? List being compiled with updates.

Thank you!

----------------------------

Submitted by Lane M Cook on Sat, 06/25/2022 - 08:06

www.tmsofknoxville.com

FACEBOOK.com/tmsofknoxville

Optum changed to 6 months between TMS effective 1/1/24 -Submitted by Lane M Cook on Mon, 06/24/2024 - 12:12

Well I got a double whammy today. A lady we treated twice before to remission had some major stresses and got depressed again. We even quit at 33 sessions due to her BDI-II going to zero. Now we are only 3 1/2 months out. To add insult to injury, I was supposed to have a doc-to-doc conversation and he/she no showed the phone call despite 3 calls to Optum to confirm and no answer.

TMS documentation examples - Submitted by Carlos A Salgado on Fri, 09/21/2018 - 09:18
Hello all, I am a new to the Clinical TMS Society. We are instituting TMS at my institution, Florida International University, in Miami, FL. Part of that implementation includes developing the documentation that we will be incorporating into the EMR. I was wondering whether anyone had any examples of wording/documentation they use for Initial motor threshold visit, TMS subsequent treatment visit, and subsequent motor threshold visit that would have the necessary elements insurance companies require for billing TMS. Thanks in advance, Carlos Salgado
--------------------------------
Carlos, I have been doing TMS for the past couple of years, and I've just recently been making my documentation templates that integrate with my EMR (Valant). This EMR integrates with Microsoft Word doc through mail merges. I'd be happy to share with you and you can make changes as you wish. my email is mshiekh@michaelshiekhmd.com Sincerely, Michael Shiekh, MD
I would love to see templates others are using too. Can you upload them to this site if possible or email to me? My email is drstjohn@gmail.com Thanks! Martha St John, MD

I would be interested in seeing the examples you have collected and thought maybe you might want to share some ideas with the society on what you discovered.  I am the new editor with the Clinical TMS society newsletter.  We are looking for some new articles to share with everyone.  Would you be willing to write a brief article discussing some of the information you have gathered?  My email is wvsleepdoc@aol.com.

Thanks!

Debbie Stultz

Submitted by Amy Nygaard on Tue, 09/15/2020 - 06:40

In reply to  by Debra J. Stultz

Good day, I see that this is an older thread, however I am starting a TMS service and am very interested in initiation, mapping, f/u templates that may have been shared. 

My email is: Amy.E.Nygaard@healthpartners.com

 Appreciate any templates or connections that we can make.

 Sincerely,

Amy

I would be interested in seeing the examples you have collected and thought maybe you might want to share some ideas with the society on what you discovered.  I am the new editor with the Clinical TMS society newsletter.  We are looking for some new articles to share with everyone.  Would you be willing to write a brief article discussing some of the information you have gathered?  My email is wvsleepdoc@aol.com.

Thanks!

Debbie Stultz

May I have a look at your templates as well?  drkeifer@brainhealthhawaii.com

 Thank you.

jason keifer

Submitted by Tihomir V. Ilic on Sat, 08/03/2019 - 04:39

Dear dr Salgado,

dear all,

I am interested in the documentation templates, as well.

Greetings from Belgrade, Serbia

Tihomir V. Ilić

my personal E-mail is tihoilic@gmail.com

--------------------------------

I was also wondering if someone would please send along an example of a TMS follow-up note. Or for that matter an initial intake note when TMS is begun/recommended.

Thanks.

Paul F. Belliveau

drbelliveau@tmscollaborative.com

I was also wondering if someone would please send along an example of a TMS follow-up note. Or for that matter an initial intake note when TMS is begun/recommended.

Thanks.

Paul F. Belliveau

drbelliveau@tmscollaborative.com

.

Submitted by Lisa Young on Wed, 04/24/2024 - 13:27

Hello, I saw some providers above looking for TMS follow up templates. I'm researching this for our clinic as well, and wondered if anyone had templates they liked for post TMS follow up, and might post here or email what they have?

Thanks so much!

Lisa Young, MD
Portland, Oregon

Below is the template I am planning to use. If you can share yours I would appreciate it.
email: drrao@instep360.org

TMS TREATMENT PRESCRIPTION/PLAN/DAILY NOTE
Date:
Patient Name:
DOB:
Dx/Treatment Target: Major Depression OCD Other:_________________
Protocol used: LDPFC___ Other:______
Total number treatments:
Schedule: Daily M-F____ Other:_____
Tapering Schedule if applicable:
Today’s Treatment number: _____
Final % MT today: _______
Complications: None___ Other_______________________
Treater: ______________
Prescriber: ______________

Submitted by Georgina Srinivas Rao on Sun, 06/09/2024 - 16:18

Can anyone comment on which rating scales you are using for depression? Are any insurances preferring one over the other? Do you prefer clinician administered or self administered? How often would you recommend it to be done? Daily?

Post Treatment - Caps (Brainsway, MagVenture, etc) - Submitted by Justine Sever Chilelli on Mon, 10/11/2021 - 13:29

Hi all,

This is a question for those of you using treatment caps during TMS procedure (brainsway, magventure, etc.). When a patient is completed with their treatment series, do you keep the treatment caps or throw them away?

Best,

Dani

 ---------------------

Submitted by Lane M Cook on Mon, 10/11/2021 - 17:29

We are a MagVenture practice and we keep everyone's caps. With a 34% recurrence rate, we see people again. You don't have to redo the coil placement. We mark the motor thresholds and their 80/100/120% MT values with dates and see if it changes. Over time those caps, especially people who have sweaty heads, look like chemistry chromatography experiments. Curiously the erasable felt-tip markers seem to run less than the regular ones. 

Submitted by Amy Nygaard on Fri, 10/15/2021 - 08:20

Hi, We are a new program this year and were just discussing this.  We are leaning toward sending them home with the patient, but are very interested in what established clinics do with the caps?

Submitted by Kevin Kinback on Thu, 04/25/2024 - 18:43

We keep our brainsway caps for many years, as they are indestructible, and may only have slight makeup stains. We re-use them for the same patients, and every month 1-2 patients return for retreatment, so we make good use of them and avoid the high cap fees for new caps.

90868 and 99214 not covered same day of service now? - Submitted by Jacqueline Lebel on Sat, 04/20/2024 - 10:33

Hi, Has anyone enountered denial of one code when both are performed and billed on same day? Previously was covered, now saying not. Thank you in advance.

Medicare Coverage for 2nd course of TMS - Submitted by Jodi Marshall on Wed, 06/08/2022 - 16:39

Does anyone know how much time there needs to be in between two courses of TMS for medicare to cover the second course? Thanks.

-----------------------

Submitted by Daniel Boyd on Mon, 02/12/2024 - 06:24

I have the same question for February 2024 in case the rules changed. Thanks for any advice.

Submitted by Lane M Cook on Wed, 02/14/2024 - 13:04

We have a patient we've treated several times then have her on a every 6 week schedule for 3 sessions which keeps her in remission. Medicare doesn't have a "must have response and wait 3 months" requirement.

RVUs for TMS providers in healthcare systems - Submitted by Daniel Fischer on Fri, 07/22/2022 - 12:56

Hello,

I work for a large healthcare system in the Pacific Northwest and started a TMS service here a little over a year ago.

Physician productivity and pay is based on RVUs generated.  As TMS does not (to my knowledge) have any RVUs assigned yet by CMS to TMS CPT codes, I am currently getting zero RVUs for TMS.  

Has anyone else faced a similar situation or know what RVUs have been assigned in any other system/hospital settings? 

Are there any proposals for RVUs for the codes 90867-90868-90868?

Thank you so much for any help or feedback!

 Dan Fischer, MD

--------------------------------

Submitted by Kyle Cothran on Fri, 12/15/2023 - 10:00

I am also interested to know what other systems assigned RVU values.

Our system has these assigned these values:
90867 - 4 wRVUs
90868 - 0.48 w RVUs
90869 - 4 wRVUs

I think the 90868 is undervalued. I've seen on other forums from 1.5 up to 6.22 RVUs for a 90868, but this substantially higher than what I listed above. Is anyone else willing to share their values?

Shopping for Device for Hospital System -Submitted by Patrick Arin Bidkhanian on Thu, 05/25/2023 - 08:26

Hello,

I am a PGY-3 Resident working with my program to purchase our first TMS machine. We have been talking to BrainsWay about purchasing their machine, but some info provide by the Apollo team made me think I need to do a deeper comparison of the available machines.

If you were buying a new machine today, which would you buy and why? Thank you!

-----------------------------------

Submitted by Lane M Cook on Fri, 06/02/2023 - 16:10

Studies show no improvement in remission/response rates among devices. The main determinants are initial price, price to operate, and coil replacement/service agreements. When I last heard, the Brainsway device is up around $200,000 and the rest are all under $100,000. I believe one is under $50,000. The Neurostar is unique in that it is the only device that after spending nearly $100,000 you must pay about $75 per session. Also most device manufacturers have sales reps who have satisfied clients happy to discuss the pros and cons of their machines. Sadly it seems many practices purchase machines with little to no comparison shopping.

Submitted by Leena Rajagopal on Mon, 10/09/2023 - 18:27

In reply to  by Lane M Cook

While Brainsway maybe higher but the current prices between machines don't seems to be as drastic as mentioned here. None of the compan8es so far have been below 100K besides the lite versions from 1 company. Am I missing something?

Submitted by Patrick Arin Bidkhanian on Fri, 06/09/2023 - 14:30

Thank you for your comment, yeah it seems like the products are similar though the companies want to seem distinct. I think you are right in that its the customer service experience that would probably differ the most. Thank you again.

Influencing Nevada medicare rates set by select committee - Submitted by John Reitano on Fri, 08/11/2023 - 11:45

It is my understanding that the average national medicare rate for TMS (90868) is $280. Nevada is currently at $130. I was also told that Arizona had an even lower rate at one time, but was able to lobby for an increase. I am doing anatomical and functional neuronavigation with a Nextstim device. My costs, experience and credentials are well above the national average. The President of the Nevada Psychiatric Association has admitted that this is outside her wheelhouse. An abundance of NP's and low medicare rates give commercial insurance justification for paying no interest in discerning the quality of patient care and thus low-balling doctors. I would like to hear of others' experience in going about requesting increased medicare reimbursements. Thank you.

Where can I find malpractice insurance for my technicians? Have PRMS for myself, they wont cover them, but want them to have it - Submitted by Kari Case Heistand on Mon, 05/23/2022 - 10:18

I have PRMS for my own malpractice insurance for my private practice that also does TMS.  PRMS says that to cover me for treatments completed by my technicians in my clinic (who have both been trained by criteria developed by Magstim and who also happen to be an RN and a registered respiratory therapist) that my technicians need to have their own individual coverage and that I need to send COI's for this to PRMS.

I'm happy to get coverage for my technicians, but PRMS says they don't sell that type of insurance.  We have contacted a few insurers so far, who say they are happy to cover my technicians, but only if I switch all of my malpractice to them, which I really don't want to do unless I have to.

Any advice?

--------------------------

Submitted by Sonni Elliott on Fri, 08/04/2023 - 10:02

I have the same question. They are fully trained and we have a AED in office and all completed BLS, Ive trained them on seizure protocol. It still feels they should have some malpractice coverage???

Insurance denial of iTBS for TRD - Submitted by Edgar Castillo-Armas on Tue, 06/06/2023 - 09:52

I wanted to share my experience with a denial of TMS treatment utilizing iTBS by Anthem Blue Cross of California. I submitted an appeal and the physician reviewer stated that it is "company policy" at this time to deny any requests for treatment if the TMS Center is planning to use iTBS. That was a surprise, I never heard about iTBS not being FDA cleared for treatment of TRD. Is this a new policy by insurance companies? Is it legal to dictate how a physician should practice? Are there any contraindications to iTBS that I don't know about? Please send your comments.

----------------------

Submitted by Schuyler Ellis on Mon, 06/12/2023 - 16:51

Edgar, unfortunately, there are still a handful of insurers that still consider TBS to be investigational and they specifically do not allow it (Anthem, United/Optum most notoriously). Typically, you can find this in their medical policy. Anthem does hide its policy though, so you do have to request it from the physician reviewer. However, you should be able to resubmit, or complete a P2P or appeal, and just tell them you will do a standard, non-TBS, protocol and they will allow it.

Regarding your questions on legality - I can't answer those...although I would love another opinion, especially from a lawyer.

Resuscitation Standards and Emergency Protocol - Submitted by Suzete Sousa Lourenco on Fri, 06/09/2023 - 10:10

What would you consider adequate resuscitation support and must-have medical equipment in an outpatient TMS clinic?

Insurance contracting to provide TMS services only, not medication management - Submitted by John P. O'Reardon on Sun, 04/11/2021 - 02:43

For the first time my practice is looking to enroll with some selected insurances for delivery of TMS treatment.

For medication management we are currently self pay only. The tricky bit is we are seeking to enroll to provide TMS services only through insurance but not medication management.

My healthcare attorney in NJ tells me this is possible but I would first go through credentialling and then when it comes to the signing the contract ask for or insist upon this waiver. 

We do not plan to take Medicare. 

I wonder if any of colleagues have experience of such an arrangment with an unsurance company whereby you provide TMS services only?

Any guidance appreciated.

Johnny O'Reardon

--------------------------------

Submitted by Degan Dansereau on Thu, 10/14/2021 - 18:36

Dr. O'Reardon, I happened to come upon your post from April and was wondering if you were able to carve out TMS srvices with insurance providers as you suggested. Could you tell me how it went? Thank you.

Submitted by Lane M Cook on Fri, 06/02/2023 - 16:14

I understand that one practice has been to get a group NPI number for the TMS practice and keep the separate NPI number for the med management. You could enquire if that would work.

Requirements for TMS Advertising - Submitted by Suzete Sousa Lourenco on Wed, 02/22/2023 - 10:51

Hi all, 

I am a TMS tech working for a small private practice and the doctor I work for is looking into local commercial advertising for TMS in her practice. I have been looking into FDA advertising guidelines, as well as each individual platform's advertising guidelines for medical devices, and have not found much information. Does anyone have any experience with this, or know of any specific considerations she should follow when advertising for TMS?

I appreciate any guidance anyone can offer!

------------------------------

Submitted by Alfredo Herrera Arellano on Fri, 03/10/2023 - 08:26

I am not familiar with any FDA guidelines related to advertising for TMS. My takes on advertising which is very effective at bringing in customers for TMS are as follows:

1. Go with the news station that has the highest ratings for the times you want to advertise. There is a report that is available that compares all TV stations for each hour and it says who has the highest ratings. No need to invest money on a station that offers a better deal, but no one is watching.  

2. Look at the demographics of the audience that is watching that station. Does is match the target population for TMS clients?

3. This next point is the most important. You and the doctor need to come up with the script. Marketing staff for the TV stations are used to developing commercials which bring in more business or volume. In my case, I did not want more patients, but more TMS patients. You only have 30 seconds and that amounts to a brief script. The whole focus should be on TMS.

4. Your provider needs to be on camera. S/he needs to brand himself/herself. Some do not want to do this and therefore s/he needs to decide how bad s/he wants to increase his TMS volume. Patients want to know who the provider is. Utilizing stock images does not make your commercial genuine or authentic. I use my staff, family members or friends as actual actors. It represents our culture and audience. 

5. As long as you don't make any claims or misrepresentations about TMS that are not evidenced based, you will be fine. 

6. Nine out of ten patients do not know what TMS is. The knowledge deficit is immense and commercials educate people and they are eager for other options. Commercials work.

7. Finally your website should also be up to par to match your commercials. I have some commercials and testimonials in my website. www.aapsychiatry.com

I hope this helps. 

prior authorization - Submitted by William Michael Reding on Wed, 05/09/2018 - 18:49

I'm new to TMS and looking for resources to help understand (as best I can) the prior authorization process. Any suggestions/direction would be much appreciated. - Michael

----------------------------

Submitted by Lane M Cook on Tue, 05/15/2018 - 13:17

We're supposed to put a link to this on our site but I don't see it. Go to https://neurostar.com/ and scroll down almost to the bottom. Under "Neurostar is covered by most health plans" is a drop down list of type of insurance (government aka Medicare, Tricare, Medicaid) and commercial. Select the insurance you want to inquire about and will send you to a link for their criteria but not reimbursement rates. This is for any FDA cleared device, not just Neurostar. Most plans require a failure of or intolerance to 4 different antidepressants and many require a failure of psychotherapy as well. The other interesting idea is a company that was a vendor at the meeting, Claimly. For 5% of reimbursement they will do the billing for TMS but pay you upfront. https://myclaimly.com/landing I don't know anything about that company. Good luck! Lane

Hi Michael,

I would do the following since each carrier has different forms or requirements. The best ten page document documenting the need for TMS will be denied because you are not using the carriers "form."

1. Obtain a list of all the carriers that you are credentialed with.,

2. Go online and review their TMS policy in the Medical Policies section. Get very familiar with the criteria for each payor. You should get to the point where you will automatically know what the criteria for the payor requires (2-4 different antidepressants, psychotherapy, MD present on site, defibrillator, etc...)

3. Download the "TMS Prior  Authoriation Form" from each of the carriers that you will be requesting TMS authorization with fax or email information.

4. Keep each of the policies and Forms (they all vary) in a binder and when you have a patient that meets the criteria, fill it out and submit. 

5. Follow up in 5 days (most companies tell you they have 10-15 work days to answer), but sometimes they did not get the form, or the form is updated and you need to resend it, etc ..

6. A tedious process, but if not followed for each carrier, you will not get approved.

Best of luck,

Alfredo H. Arellano

Annual Hearing Screening for Technicians - Submitted by kdaddario@sheppardpratt.org on Thu, 02/16/2023 - 06:34

Are annual hearing screens becoming a standard of occupational health assessment for TMS technicians?  Please let me know if your practice is doing this.  Thank you!  Kathy Daddario, RN, Sheppard Pratt, Baltimore, MD

TMS Technician Retention Strategies

Have you dealt with TMS Technician retention issues? I work at TMS Centers in Kentucky/Indiana and we're currently dealing with TMS Technician retention issues.

If you've implemented any retention strategies that have worked/or haven't worked... please list them. Any help is greatly appreciated! 

Best,
Dani

dani.lutzke@oasistms.com

how should I have my contract written - Submitted by Jordan M. Spencer on Mon, 10/17/2022 - 05:47

Hey all,

I am  Beginning conversations with a private practice Which I suspect I will end up signing on with as my first job job out of residency. I anticipate for just general clinical duties I'm going to have a 70% 30% split. That being said I can appreciate the extra manpower and device cost associated with TMS. Should I ask for 70% 30% split on the profits made from the machine after additional overhead is accounted for? Should I Simply ask for a 60/40 split on money generated from TMS or would you suggest to do something different?

I want to be fair to the practice and not gouge them but at the same time I don't want to get short change.

Thanks in advance

--------------------------------

I confess that I do not know what a "reasonable split" is. That being said, we are not generally taught in either medical school or residency about managing financial issues. And because of this, newbies are often vulnerable to exploitation. 

There is a shortage of psychiatrists across the country. You therefore do not have to settle for suboptimal contracts unless there are extenuating circumstances. Prior to signing any contract, you should consider your goals and expectations. Is there a particular income you require? Will the arrangements you make allow you to meet that income? Is there a location you are inflexible about (such as needing to stay in a specific area because of a spouse)? How much flexibility will you have in managing your schedule? Will you be required to see everybody for 15 minutes sessions; be allowed to see some for 60 minutes; be allowed to do psychotherapy if desired; only be allowed 60 minutes (including documentation time) for a new psych eval; have documentation time blocked out in your schedule; etc.? Does the person you're joining appear to be someone who will value you as an equal  partner or as someone to be exploited and then discarded when used up? What is the mix of patients in the practice between self-pay, private insurance, Medicare, and Medicaid? Will new evals be evenly distributed regardless of their coverage or will you be assigned all the Medicare patients while the owner gets the more lucrative private pay? How will you know if there is an even distribution?

If you investigate locum tenens opportunities, you can get an idea of what hourly reimbursement you can get in different areas. (Although locum tenens companies usually only offer claims made malpractice so you might consider purchasing your own occurrence policy in addition.)

If you contact the different TMS machine manufacturers, they will all tell you how much each machine costs and how the cost can be amortized over time. Knowing how much the practice is paying monthly for the machine, and how much reimbursement is, might give you an idea of what would be reasonable IN YOUR VIEW for what percent the practice should take. And whether you do the TMS yourself or supervise a technician will also factor into the equation.

When I was in private practice, the rent was relatively insignificant. However, it was in a small town and not in NYC on Park Ave. Having a billing clerk is invaluable to getting reimbursed and this is certainly worth paying for. 

Prior to signing any contract, it should be reviewed by a lawyer with expertise in these type of contracts. Your local/state medical/psychiatric society might be able to give you some names. You don't want to inadvertently violate fee splitting laws. Or inadvertently sign away your soul (such as by signing a noncompete contract within 200 miles, an indemnification clause, or a contract you can't leave without significant penalty if circumstances require, etc.)

There are many articles on physician contracts. Below is one although it left off discussing non-compete clauses. When I went to work a few years ago for one of the area's largest nonprofits in their halfway houses, I was flabbergasted to discover they had included an indemnification clause in the contract. I refused to sign until after it was removed.

https://sullivanlegal.us/7-dangerous-physician-employment-contract-terms/

There is one other point I'd add but think it better to send you privately off-list. If you email me your address at harlankosson@aol.com I will do that. 

Good luck for a successful and fulfilling career.

Submitted by Jordan M. Spencer on Thu, 10/20/2022 - 14:38

Wow this is stupendous! Thank you!

how should I have my contract written - Submitted by Jordan M. Spencer on Mon, 10/17/2022 - 05:47

Hey all,

I am  Beginning conversations with a private practice Which I suspect I will end up signing on with as my first job job out of residency. I anticipate for just general clinical duties I'm going to have a 70% 30% split. That being said I can appreciate the extra manpower and device cost associated with TMS. Should I ask for 70% 30% split on the profits made from the machine after additional overhead is accounted for? Should I Simply ask for a 60/40 split on money generated from TMS or would you suggest to do something different?

I want to be fair to the practice and not gouge them but at the same time I don't want to get short change.

Thanks in advance

--------------------------------

I confess that I do not know what a "reasonable split" is. That being said, we are not generally taught in either medical school or residency about managing financial issues. And because of this, newbies are often vulnerable to exploitation. 

There is a shortage of psychiatrists across the country. You therefore do not have to settle for suboptimal contracts unless there are extenuating circumstances. Prior to signing any contract, you should consider your goals and expectations. Is there a particular income you require? Will the arrangements you make allow you to meet that income? Is there a location you are inflexible about (such as needing to stay in a specific area because of a spouse)? How much flexibility will you have in managing your schedule? Will you be required to see everybody for 15 minutes sessions; be allowed to see some for 60 minutes; be allowed to do psychotherapy if desired; only be allowed 60 minutes (including documentation time) for a new psych eval; have documentation time blocked out in your schedule; etc.? Does the person you're joining appear to be someone who will value you as an equal  partner or as someone to be exploited and then discarded when used up? What is the mix of patients in the practice between self-pay, private insurance, Medicare, and Medicaid? Will new evals be evenly distributed regardless of their coverage or will you be assigned all the Medicare patients while the owner gets the more lucrative private pay? How will you know if there is an even distribution?

If you investigate locum tenens opportunities, you can get an idea of what hourly reimbursement you can get in different areas. (Although locum tenens companies usually only offer claims made malpractice so you might consider purchasing your own occurrence policy in addition.)

If you contact the different TMS machine manufacturers, they will all tell you how much each machine costs and how the cost can be amortized over time. Knowing how much the practice is paying monthly for the machine, and how much reimbursement is, might give you an idea of what would be reasonable IN YOUR VIEW for what percent the practice should take. And whether you do the TMS yourself or supervise a technician will also factor into the equation.

When I was in private practice, the rent was relatively insignificant. However, it was in a small town and not in NYC on Park Ave. Having a billing clerk is invaluable to getting reimbursed and this is certainly worth paying for. 

Prior to signing any contract, it should be reviewed by a lawyer with expertise in these type of contracts. Your local/state medical/psychiatric society might be able to give you some names. You don't want to inadvertently violate fee splitting laws. Or inadvertently sign away your soul (such as by signing a noncompete contract within 200 miles, an indemnification clause, or a contract you can't leave without significant penalty if circumstances require, etc.)

There are many articles on physician contracts. Below is one although it left off discussing non-compete clauses. When I went to work a few years ago for one of the area's largest nonprofits in their halfway houses, I was flabbergasted to discover they had included an indemnification clause in the contract. I refused to sign until after it was removed.

https://sullivanlegal.us/7-dangerous-physician-employment-contract-terms/

There is one other point I'd add but think it better to send you privately off-list. If you email me your address at harlankosson@aol.com I will do that. 

Good luck for a successful and fulfilling career.

Submitted by Jordan M. Spencer on Thu, 10/20/2022 - 14:38

Wow this is stupendous! Thank you!

Product Announcements

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Free Neurostar TMS System 1.0 - Submitted by Alfredo Herrera Arellano on Tue, 01/03/2023 - 09:18

Free Neurostar TMS System 1, fully functional, purchased in 2011, last used in August 2022, serviced every other year to the first taker. Taker has to pay for shipping costs and set up reactivation use with Neurostar. TMS system has performed 3,755 treatments over a ten year period. Psychiatrist is retiring and closing practice and does not have a need for TMS system. 

Contact: Irma Ramirez at 915-526-7680 or aram3000@att.net for further information. 

ADHD neurostimulator - Submitted by Mark Xuereb on Wed, 08/14/2019 - 03:56

Hi,

Does anyone have the details of the company who manufactures this FDA approved product? Any backing evidence?

 -------------------------------

Submitted by Ali Hashemian on Thu, 07/01/2021 - 15:44

EndeavorRx®, the first-and-only prescription treatment delivered through a video game

https://www.akiliinteractive.com/

 

The Monarch® eTNS® System is the First FDA Cleared Device for Treating Pediatric ADHD.

https://www.neurosigma.com/

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MT with Accelerated Protocol - Submitted by Ali Elahi on Mon, 06/27/2022 - 11:44

How often is MT done with the SNT accelerated protocol?  I could not find any mention of MT in the papers from Stanford and Nolan Willaims?

TMS DURING PREGNANCY - Submitted by Martha B Koo on Tue, 10/26/2021 - 21:56

The research committee would like to identify providers who have treated pregnant women with TMS.  If you are willing to identify yourself, can you post your name, the TMS device you use, and any objective rating scales you track? Thank you

rTMS no better than sham treatment? - Submitted by Mark Xuereb on Fri, 07/06/2018 - 13:08

Does anyone have any comments on this?
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2686050...
Mark

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Submitted by Michelle Cochran on Mon, 08/06/2018 - 18:45

Read the conclusion in the article... they do a really good job talking about why placebo worked so well for the veterans. This article doesn't show that TMS didn't work... just that Placebo in Veterans really worked.

Submitted by Michelle Cochran on Mon, 08/06/2018 - 18:45

Read the conclusion in the article... they do a really good job talking about why placebo worked so well for the veterans. This article doesn't show that TMS didn't work... just that Placebo in Veterans really worked.

Submitted by Todd Hutton on Tue, 08/07/2018 - 22:39

In reply to  by Michelle Cochran

But if all this attention brought on a 40% placebo response in both groups, wouldn't the active treatment group have an additional boost from the benefit of active treatment? The only explanation would be that the same subset of TMS responders were the same group who responded to placebo. I think the fact that there was a placebo response of 40%, versus 5% in the original Neuronetics FDA trial, suggests that this was just a poorly run study.

A recently published multicenter Veterans Affairs (VA)–sponsored study of 1522 patients that compared antidepressant switching with augmentation in patients who had failed at least 1 antidepressant medication resulted in relatively low remission rates (in the range of 22.3% to 28.9%).

In the Yesavage rTMS VA study there was more treatment resistance:  To enter the trial, participants had to have failed at least two prior drug therapies and meet DSM-IV criteria for major depressive disorder. Patients with certain psychiatric comorbidities were excluded, but not all: 49.4% of the sample had post-traumatic stress disorder and patients with substance use disorder comprised 53.7%.  

Still there was a 41% Remission Rate in active and 37% (rounding off) in sham...In comparison  to the antidepressant VA study, rTMS treatment still beats medication treatment in a similar VA population. 

I agree with Todd that there may be complication with the design with more men, PTSD and substance abuse as inclusion criteria.  

Submitted by Geoffrey Grammer on Tue, 07/23/2019 - 16:34

The pulse sequence was not what is typically used clinically.  The coil used is not the same as the coils from both vendors who have FDA submitted clinical trials.  Its hard to extrapolate beyond the specific cicumstances examined in the trial.

Submitted by Geoffrey Grammer on Tue, 07/23/2019 - 16:34

The pulse sequence was not what is typically used clinically.  The coil used is not the same as the coils from both vendors who have FDA submitted clinical trials.  Its hard to extrapolate beyond the specific cicumstances examined in the trial.

Submitted by Mark Xuereb on Mon, 09/09/2019 - 11:23

Thank you all for your response and explanations...apologies for the delay. M

Submitted by Spencer Zimmerman on Sat, 10/31/2020 - 09:07

I do wonder how thoroughly they screened for mTBI and TBI. There are far too many vets who have those injuries but are not diagnosed. You cannot expect the same results when there are other factors not being looked at.

Accelerated TMS-3 treatment sessions a day for 3 days? - Submitted by Mark Xuereb on Sun, 08/05/2018 - 11:30

Does anyone have any experience delivering 3 treatment sessions a day for TRD? We deliver 3 TMS sessions a day (200 pulses per session with 15 min breaks in between) for 3 consecutive days. BDI scores drop after day 3.

--------------------------------------

Submitted by Boris Kawliche on Sat, 08/08/2020 - 11:51

We are currently treating a suicidal woman with five attempts on her life since May for 15 minutes with a 30 minute break and another 15 minutes of a Theta Burst blend of intermitent and continuous betwen the L and R DLPFC. We plan to treat her five days a week for three weeks and she has completed her first week. So far no convincing improvement but she did have at least one fairly positve day according to her family which was a pleasant surprise to them and gave hope. We have an EEG done in the office indicating dyfunction in her L occipetal lobe at 01 so debating if we should treat this area instead at some point. EEG will be repeated next Friday.

TMS Adverse Events

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patient with multiple sclerosis - Submitted by Shannon Johnson on Tue, 11/14/2023 - 12:53

I have a patient that I am treating that also has MS that I have not been able to get above 90% treatment due to severe migraine headaches after her treatment. I was going to offer her theta burst treatment in an attempt that a shorter treatment time may lessen the chance of a migraine or severe headache. Does anyone have any ideas or suggestions?

Anxiety/Agitation/Insomnia - Submitted by Eric A. Robbins on Wed, 10/18/2023 - 19:58

Hello everyone. Need help for a patient who reached out to me after 6 months of receiving TMS complaining of persistent anxiety/agitation/insomnia. He received a course of left sided rTMS and right sided iTBS. Would like to know if anyone has had a similar patient experience or to offer any suggestions or thoughts on how to help this patient. TIA for any and all help.

Recent adverse event - Submitted by Evelyn Hazlett on Mon, 12/20/2021 - 13:10
  • Hi all, I’m new to the listserv so forgive me for any goof ups.

    I have a patient who had to terminate TMS sessions prematurely due to an adverse event. About 10 minutes into his treatment he began having severe left arm tremor and left-sided neck and arm pain. When treatment was stopped the symptoms of abated.  There was concern the TMS was causing simple partial seizures and his future TMS treatments was terminated. 

    Has anybody come across anything like this or similar? Could this have just been poor placement of the magnet? Would he no longer be a TMS candidate in the future? Any thoughts would be appreciated.

    Evie Hazlett

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Protocol for Reporting Adverse Event: Seizure - Submitted by Kevin Field on Thu, 05/25/2023 - 10:29

Hello!

Our clinic recently had a tonic-clonic seizure occur during a TMS treatment. The patient ended up doing well, seizure resolved without intervention, EMS arrived and the patient had a ED workup.

Of course, their treatment was discontinued (thankfully they were already at the taper phase and had a response in depression scales).

How should our clinic go about reporting the incident? What medical bodies should know about it? FDA? State Medical Board?

Guidance would be greatly appreciated...

Kevin Field PA-C
Sage Neuroscience Center
Feel free to text or call me at 208-407-6923

------------------------------------------------------

Submitted by Lane M Cook on Fri, 06/02/2023 - 15:21

Contact the manufacturer of your TMS device and they will know how to report to the FDA. You should also enter it at Medwatch and the site is here:

https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=profes…
It would be informative if you would let this forum know what device and what TMS protocols were in use. Also if the patient had slept in the prior 24 hours. In the Dunner article one seizure was reported in a nurse who was sleep deprived, worked a 24 hour shift, was on a stimulant and bupropion. I believe TMS was resumed after she was cleared and slept. We tell patients to call and not come in if they don't get at least 2 hours of sleep the night before. In a survey published here in Brain Stimulation Journal https://www.brainstimjrnl.com/article/S1935-861X(21)00118-2/fulltext they reported this: 18 seizures reported in 586,656 sessions and 25,526 patient sacross all device manufacturers.The overal lseizure rate was 0.31(95%CI:0.18,0.48)per10,000sessions, and 0.71(95% CI:0.42,1.11)per1000patients.The Brainsway H-coil seizure rate of 5.56per 1000patients (95%CI:2.77,9.95) was significantly higher(p<0.001)than the three most widely used figure-8coil devices’ combined seizure rate of 0.14per 1000 patients (95%CI:0.01,0.51). This is well-known with the Brainsway device.

Trials

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Should non-urgent, non-COVID related TMS research be allowed to take place presently? - Submitted by Mark Xuereb on Wed, 06/02/2021 - 12:03

Hi all. I am all in favour of necessary, therapeutic TMS. We carry this out like you all in our clinic on a daily basis.

However, is it safe and ethically appropriate to perform non-urgent, non-COVID related research when one is necessarily within close proximity of the patient for a long enough time to potentially transmit the COVID virus? PCR results in Malta take anything from 4-72h, making the possibility of being infective a potential reality despite a negative test. As you know, a large study published in the Lancet said that a psychiatric diagnosis might be an independent risk factor for COVID-19 (Taquet, 2020) which increases the risk of infectivity. Besides, wearing hot, stuffy PPEs for every patient is not always practical and then there is the disinfection of all equipment etc. 

I appreciate this can be controversial and peppered with many variables, but I just wanted an opinion from those who have more experience in the field of research than me. 

Thanks,

Mark