Key takeaways
- Optum’s age eligibility expanded in 2026.
- Adult and adolescent medication-history requirements differ.
- A previous documented TMS response can be relevant to initial eligibility.
- Repeat treatment, maintenance, and accelerated protocols have distinct coverage rules.
UnitedHealthcare and Optum: who reviews TMS?
Your behavioral health benefits may be administered through Optum even when another company’s name appears on your card. We check the complete product information and the administrator responsible for the TMS request.
The criteria below summarize Optum’s non-Medicare policy. Medicare Advantage and Medicaid products require review of the applicable Medicare or state requirements.
Optum TMS coverage at a glance
| Coverage question | Published policy summary |
|---|---|
| Age | 15+ effective January 1, 2026 |
| Depression diagnosis | MDD; listed covered codes describe severe depression without psychosis |
| Adult treatment history | Two unsuccessful and/or intolerable evidence-based medication regimens from two classes in the current episode |
| Ages 15–17 | Two unsuccessful and/or intolerable regimens; no separate two-class requirement stated |
| Another eligibility pathway | Previous TMS response greater than 50% on a standardized depression scale |
| Fixed medication duration | No universal week minimum in the eligibility section |
| Psychotherapy or augmentation | Not separately required in the listed initial criteria |
| Symptom monitoring | Baseline validated depression scale |
| Standard course | 30 treatments plus six taper sessions |
| Repeat treatment | Initial criteria met, relapse despite ongoing care, and prior improvement greater than 50% |
| Timing | Relapse six months after the most recent treatment |
| Exclusions | TBS/accelerated protocols, maintenance/boosters, OCD, and other non-MDD indications |
Coverage question
Age
15+ effective January 1, 2026
Depression diagnosis
MDD; listed covered codes describe severe depression without psychosis
Adult treatment history
Two unsuccessful and/or intolerable evidence-based medication regimens from two classes in the current episode
Ages 15–17
Two unsuccessful and/or intolerable regimens; no separate two-class requirement stated
Another eligibility pathway
Previous TMS response greater than 50% on a standardized depression scale
Fixed medication duration
No universal week minimum in the eligibility section
Psychotherapy or augmentation
Not separately required in the listed initial criteria
Symptom monitoring
Baseline validated depression scale
Standard course
30 treatments plus six taper sessions
Repeat treatment
Initial criteria met, relapse despite ongoing care, and prior improvement greater than 50%
Timing
Relapse six months after the most recent treatment
Exclusions
TBS/accelerated protocols, maintenance/boosters, OCD, and other non-MDD indications
The medication regimen, device indication, clinical circumstances, and benefits all need review. A completed medication list alone does not establish that the applicable criteria have been met.
Authorization and the records we need
TMS is a non-routine service for which applicable Optum plans require authorization. We confirm the requirement for your particular product and use the appropriate submission process.
Helpful documentation includes:
- Psychiatric notes describing current symptoms and functioning.
- Medication regimens, doses, dates, results, and side effects.
- Details of previous TMS and its documented outcomes.
- Baseline assessments and relevant medical history.
If records are held by another clinician, let us know where you received care. Our team can explain what information is needed.
What will TMS cost with UnitedHealthcare?
Costs depend on your deductible, copayments or coinsurance, approved services, and network status. Different UnitedHealthcare products can have different benefits.
We provide an individualized estimate before treatment and explain the proposed schedule and patient responsibility.
If you are considering a change in coverage, tell us before treatment starts so we can identify which plan will apply to the expected dates of service.
A care plan that accounts for your other treatment
Your TMS consultation reviews your current medications, previous treatment, medical history, and goals. We also ask who else is involved in your care.
With appropriate consent, we can coordinate information with your prescribing clinician or therapist. That helps build a clear record of what has been tried and how your symptoms change.
Frequently asked questions
Optum administers behavioral health benefits for some health plans. The appropriate administrator and clinical criteria depend on your specific coverage.
Yes. Some Oscar and AvMed plans use Optum for behavioral health. We identify the administrator and verify your product rather than assuming all plans use identical rules.
Tell us the clinic name and treatment dates. Records of your previous course, symptom ratings, and outcome can be important to the review.
Let us know as early as possible. We review the new benefits, network status, and approval requirements before representing future sessions as covered.
Tell us which protocol you are considering. We check the proposed treatment against your plan’s coverage and explain any non-covered options before scheduling.
A clinician’s recommendation is part of the evaluation. Benefits, documentation, medical necessity, and the proposed treatment must also satisfy the applicable requirements.
Check your UnitedHealthcare or Optum TMS benefits
Florida TMS Clinic provides TMS care in Wesley Chapel and Tampa. Our team can review your benefits and help you understand the next step.
Call (813) 867-2378 or request your coverage check.
Compare TMS coverage across insurers.
Policy information checked November 1, 2026. Coverage depends on your benefits, clinical eligibility, network participation, and required authorization. Verification and authorization do not guarantee payment.
Official policy references
Medical information on this page is educational and not a substitute for professional advice. Individual results vary.