EmblemHealth has not published a current TMS medical-necessity policy for depression. As of October 7, 2026, the public record consists of two documents: EmblemHealth's Medical Technology Database, which marks TMS for conditions other than depression as not covered, and an undated TMS request form from Carelon Behavioral Health, EmblemHealth's behavioral health manager. The form is written for Carelon's commercial contracts in general, not for EmblemHealth alone. Those documents show what a reviewer is likely to ask for. They are not a full statement of the criteria, so get the criteria in writing from your plan before you start treatment.
New York City employees face a second change. The GHI-CBP plan that many city workers relied on was discontinued on January 1, 2026, and its members were moved automatically into the new NYCE PPO. That plan's behavioral health network is run by Optum, not by EmblemHealth or Carelon, so the relevant criteria may now be different.
Start here: which city plan are you in?
The right TMS document depends on the plan named on your 2026 ID card. The city's Office of Labor Relations lists these options for employees and non-Medicare retirees, among others:
| Plan on your card | Who handles behavioral health | Where to look for TMS criteria |
|---|---|---|
| GHI-CBP (with Anthem Blue Cross and Blue Shield) | Plan discontinued as of 1/1/2026 | Not applicable; members were moved to NYCE PPO |
| NYCE PPO (UnitedHealthcare and EmblemHealth, from 1/1/2026) | United Behavioral Health network, operating under the Optum brand | No NYCE-specific TMS policy is published; ask whether Optum's behavioral TMS policy applies |
| GHI HMO, HIP HMO Preferred, HIP Prime POS | Ask the plan; Carelon's form is the only public EmblemHealth-side TMS document | Request the criteria in writing |
| Aetna EPO, Anthem EPO, MetroPlusHealth Gold and others | That insurer | That insurer's policy (see the payer guides below) |
The NYCE PPO details come from UnitedHealthcare's provider FAQ dated January 2026, which states that members "will use the United Behavioral Health network (operating under the Optum brand) nationally, including the 13 downstate New York State counties". For other options, see the guides to Aetna and Empire BCBS and Anthem.
If you are on the NYCE PPO
Neither the city nor the plan has published which TMS criteria the NYCE PPO applies. Because behavioral health runs through Optum's network, the most likely reference is Optum's Behavioral Clinical Policy BH803TMS112025, which says it applies "to all lines of business unless superseded by federal or state regulations". That is an inference, not a plan statement. Ask the plan to confirm it.
If Optum's policy does apply, the main points are an age of 15 or older, two failed or poorly tolerated medication regimens from two classes in the current episode for adults, no psychotherapy requirement, and up to 30 sessions plus 6 tapering sessions. The full criteria are in the UnitedHealthcare and Optum TMS guide. UnitedHealthcare's FAQ says prior authorization "is required for certain health care services" on the NYCE PPO and lists Provider Services at 844-849-5750 for prior authorization requests.
What EmblemHealth and Carelon have published
| Document | Date | What it says about TMS |
|---|---|---|
| EmblemHealth Medical Technology Database | TMS row last reviewed 11/14/2025 | TMS for "neurologic or psychological indications other than depression" is not covered for Commercial, Medicare and Medicaid members; examples include OCD with BrainsWay deep TMS, migraine, stroke and tinnitus |
| Same database, federal note | Same | For federal (FEHBP) members, "FDA-approved" procedures and devices (the database's wording; TMS devices are FDA-cleared) "may not be considered investigational for the purposes approved" |
| Carelon Behavioral Health rTMS request form (commercial contracts) | Undated | Lists the information a reviewer asks for (below) |
The table quotes the database and the form directly. The practical meaning of the first row is that depression is the only TMS indication with any route to coverage. OCD treated with deep TMS is listed as not covered, even though some other insurers, Cigna among them, do cover it.
What the Carelon request form asks for
A request form is not a policy, but it shows what a reviewer will check. Carelon's commercial form asks for:
- An age band of 18 to 70.
- A diagnosis of F32.2 or F33.2, which are severe major depression without psychotic features.
- A pre-treatment score on a validated scale such as the PHQ-9, BDI, HAM-D, MADRS, QIDS, IDS-SR or GDS.
- Either two adequate medication trials of at least six weeks from two classes, or intolerance of four trials from two classes.
- A table of medications with names, doses and dates.
- Any TMS or ECT within the past three years, with the response.
- Attestations that rule out a history of mania, hypomania or mixed episodes; active substance use or an eating disorder in the past year; recent OCD or PTSD; a psychotic disorder; a suicide plan or recent attempt; listed neurological conditions; and VNS leads in the carotid sheath.
- A physician order with on-site supervision, plus the servicing clinician's NPI and tax ID.
Two items deserve attention. The form's upper age of 70 has no counterpart in Medicare's New York policy or in the Aetna, Cigna and Optum policies, none of which states an upper age limit; if you are over 70 and on an EmblemHealth commercial plan, ask how the plan handles that. The exclusion for recent PTSD or OCD can affect people whose depression occurs alongside those conditions. TMS is not a crisis treatment. If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
What is not published, and how to get it
No current EmblemHealth or Carelon TMS medical-necessity guideline for depression was found, so the session limit, retreatment rule, psychotherapy requirement and position on theta burst or accelerated TMS are not public. Do not assume they match another insurer's. Ask the plan:
- Which written TMS criteria apply to my plan, and what is the document's name, number and revision date?
- Who reviews the request: EmblemHealth, Carelon or Optum?
- Is prior authorization required, how many sessions are approved at first, and is theta burst stimulation covered?
- Is my coverage fully insured or self-funded?
The answer to the last question matters. For group coverage regulated by New York, insurers must make their mental health medical-necessity criteria available to members on request. New York's financial regulator notes that when an employer self-funds coverage, "an insurer may still process claims, but New York protections don't apply". The parity guide, New York mental health parity and TMS claims, explains which rules follow from each answer. Request the criteria in writing and keep the reply; it becomes evidence if you need to appeal.
If the request is denied
For state-regulated plans, New York law allows no less than 45 days after a denial notice to file an internal appeal, which must be decided by a clinical peer who did not make the first decision. After a final denial for lack of medical necessity, or because a service is considered experimental, you have 4 months to request an external appeal through the Department of Financial Services. The plan may charge $25 per external appeal, capped at $75 a year, and the fee is refunded if the denial is overturned. The step-by-step version for patients is in how to appeal a TMS denial in New York.
Federal employees with EmblemHealth
EmblemHealth's database notes a different standard for members in the Federal Employees Health Benefits Program: there, procedures and devices the database calls "FDA-approved" may not be considered investigational for the purposes approved, and coverage is judged on medical necessity. TMS devices are FDA-cleared, not approved, so ask the plan how it applies that note to TMS. Federal plans are covered in TMS coverage for veterans, TRICARE and federal employees.
Before you begin
Coverage is one question; whether TMS fits your depression is another. The guide to who delivers TMS and why oversight matters covers the clinical side. The physician's guide to TMS covers the evidence, and the TMS service page explains how to start a conversation about whether TMS is an option.
Frequently asked questions
Does GHI cover TMS for city employees in 2026?
GHI-CBP ended on January 1, 2026, and its members moved to the NYCE PPO, whose behavioral health network is Optum's. Ask the NYCE PPO which TMS criteria it applies and whether prior authorization is needed.
Does EmblemHealth cover deep TMS for OCD?
No. EmblemHealth's Medical Technology Database lists TMS for indications other than depression, including OCD with deep TMS, as not covered for Commercial, Medicare and Medicaid members.
Why can't I find EmblemHealth's TMS policy online?
No current EmblemHealth or Carelon TMS guideline for depression was publicly available in October 2026. For state-regulated group coverage, New York law requires insurers to provide their mental health medical-necessity criteria on request.
Does Carelon's form require six or eight weeks per medication trial?
The undated Carelon commercial request form asks for two adequate trials of at least six weeks from two classes, or intolerance of four trials from two classes. Confirm the current requirement with the plan.
Who can help me if my city plan denies TMS?
Start with the plan's internal appeal. For state-regulated coverage, New York's Department of Financial Services runs external appeals and takes complaints; ask the plan first whether your coverage is fully insured or self-funded.
Sources
- EmblemHealth Medical Technology Database. EmblemHealth, 2025. emblemhealth.com
- Carelon Behavioral Health Repetitive Transcranial Magnetic Stimulation Request Form (commercial contracts). Carelon Behavioral Health, undated. carelonbehavioralhealth.com
- Summary of Plans (NYC Health Benefits Program). NYC Office of Labor Relations, 2026. nyc.gov
- City of New York Employees (NYCE) PPO plan: Frequently asked questions (PCA-1-26-00070-E&I-FAQ_01292026). UnitedHealthcare, 2026. uhcprovider.com
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation (BH803TMS112025). Optum Behavioral Health Solutions, 2026. providerexpress.com
- Mental Health and Substance Use Disorder Information. NY Department of Financial Services, 2026. dfs.ny.gov
- NY Insurance Law Sec. 3221 (group mental health coverage). New York State Senate, 2026. nysenate.gov
- NY Insurance Law Sec. 4904 (Appeal of adverse determinations by utilization review agents). New York State Senate, 2026. nysenate.gov
- File an External Appeal. NY Department of Financial Services, 2026. dfs.ny.gov
- Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
- LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal via CMS Medicare Coverage Database, 2026. cms.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (CPB 0469). Aetna, 2026. aetna.com
Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.
The information provided on this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
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