Getting Insurance Coverage for TMS for OCD: Be Persistent!

By Carlene MacMillan, MD

When TMS for OCD was cleared by the FDA in the late summer of 2018, those of us that work with patients with severe OCD breathed a sigh of relief as this had been a long time in the making. Patients began calling our office looking to get started right away. There was just one small catch- insurance companies had no authorization process in place to cover TMS for this indication. In fact, they generally still do not over 2 years later. This should not come as a surprise. When TMS was FDA-cleared for depression in 2008, major insurances took quite some time developing coverage guidelines and it was not until 2013, 5 years later, that policies started appearing. We cannot wait 5 years for TMS to be covered for OCD! In our practice we knew we would have to be unflappable and steadfast advocates for our patients to get the coverage they desperately need. So far, we have had some success with various commercial insurance plans in securing coverage for this indication. We thought it would be potentially inspiring to others if we outlined a bit of our process.

We are very fortunate in our practice to have a Patient Advocate, Leah Link, who has worked with us for several years and has developed working relationships with various insurance carriers around TMS coverage. If a psychiatrist in our practice wants a patient of theirs to get TMS for OCD, the patient’s first call is to Leah. Leah is very up front that for some plans, they should expect it to take up to 6 months to jump through a series of hoops that culminate in coverage at long last. Here is a little snapshot of the typical process:

1. If they are willing to go on this journey, it starts with us submitting an authorization, typically using a form that was designed for Major Depressive Disorder and attaching a letter indicating the rationale for seeking coverage for OCD along with a copy of the FDA clearance. Once we went through this entire process once, we had an external appeal letter overturning an initial denial and were able to redact all identifying information. We attach this to the initial authorization requests to say, basically, “See, this worked before and we are very persistent!”
2. We fully anticipate getting an initial denial. We briefly clench our fists in frustration but it’s back to work!
3. We then submit an internal appeal. We again include a letter about how it is an FDA-cleared treatment but up the ante a bit and emphasize that the denial is not in accordance with this clearance and is not based on any empirical evidence. We include citations of the studies involving TMS for OCD as evidence to the contrary.
4. If the internal appeal is denied, we receive the ominous sounding “Final Adverse Determination.” Don’t let the wording fool you! Don’t give up!
5. The next step is a level 3 external appeal which is conducted through an independent third party. The denial letter should indicate how to initiate this process. Include a signed consent from the patient to appeal on their behalf and submit all information and denials submitted up until this point. Note that for self-funded insurance plans, this option may not be available as they are not bound by the same regulations as commercial and state funded plans. Also note that you only have one shot per treatment course to pursue this. We do not recommend the patient start to pay privately for treatment until a decision is made if going this route. If the patient would prefer to just start the treatment and pay privately, we recommend holding off on the external appeal until the course has been completed.
6. Wait. It will seem longer than it should. It always does.
7. Receive notification that the denial has been overturned and authorization has been granted.
8. Share in the joy with the patient that the treatment has been approved and begin the course of TMS!

If the external appeal overturns the original denial, we recommend also filing a complaint with the state to help with enforcement of the decision and to set precedent for future cases. You can go to Www.paritytrack.org to find out what state agency this is in your state if the adverse determination does not indicate where to turn. You can also submit on that website information about any challenges faced to help future patients have a smoother path to approval.

While the nuances and terminology may vary slightly from insurance plan to insurance plan and state to state, the general principles are the same. The FDA-clearance is on our side here and persistence pays off! We also try to remember that the plans are quite bureaucratic and slow-moving and simply do not have protocols immediately in place to accommodate these treatments, which are expensive for the insurance company to pay. So having a doc-to-doc call with a physician who has no power to approve something that does not have a written protocol in place on the payer’s end is not that reviewer’s fault. No matter how much evidence you are able to rattle off, it is likely it will be initially denied. I do think in the long run for severe OCD, where patients frequently seek out expensive residential treatment or even inpatient psychiatric hospitalizations, TMS is a cost-effective option but we need more data to really demonstrate that definitively in ways that are compelling to the payers.

The Clinical TMS Society Insurance Committee, which I am a member of, has drafted some guidelines for insurance companies to incorporate TMS for OCD in their covered services but we recognize it is an uphill battle. We would encourage you to share with the Society any triumphs or disappointments you encounter in attempting to get coverage for TMS for OCD so we can learn from each other to the benefit of our patients.

Disclaimer: This article represents the individual opinion and work of the author not the CTMSS.