Pennsylvania Medicare TMS Coverage

Medicare TMS in Pennsylvania

Pennsylvania Medicare beneficiaries are served by Novitas Solutions as the Medicare Administrative Contractor (MAC). Novitas covers TMS for treatment-resistant major depressive disorder under their local coverage determination (LCD) policy.

Novitas TMS Coverage Policy

Novitas handles Medicare Part B for Pennsylvania and has established TMS coverage criteria aligned with national Medicare guidelines:

1. Diagnosis: Major Depressive Disorder (MDD), moderate to severe
2. Medication trials: At least 2 adequate antidepressant trials from different drug classes
3. Duration: Each trial at therapeutic dose for at least 6 weeks
4. Prior authorization: Required before treatment begins
5. Provider: Physician-supervised TMS at an approved facility

Finding TMS Providers in Pennsylvania

Pennsylvania has a strong network of TMS providers, concentrated in:

• Philadelphia metro: University of Pennsylvania, Jefferson, Temple, and affiliated private practices
• Pittsburgh: UPMC and Allegheny Health Network TMS programs
• Harrisburg/Hershey: Penn State Hershey Medical Center
• Allentown/Lehigh Valley: Growing number of outpatient TMS clinics
• Scranton, Erie, Lancaster: Regional options available

What You’ll Pay

Under Original Medicare Part B:

• Deductible: $240
• Coinsurance: 20% of Medicare-approved amount
• For 36 sessions: Approximately $1,200–$2,400 total out-of-pocket
• Medigap: May cover the 20% coinsurance

Pennsylvania Medicare Advantage

Medicare Advantage plans operating in Pennsylvania (UPMC Medicare Advantage, Geisinger Gold, Aetna Medicare, Humana) each set their own prior authorization requirements. Contact your plan directly.

How to Get Started

1. Talk to your primary care doctor or psychiatrist about a referral
2. Request documentation of your medication history
3. Find a Novitas-participating TMS provider in our directory
4. The clinic handles prior authorization submission

What You Need to Know