Referring a Patient for TMS: A Guide for Therapists and Physicians

Refer for TMS when an adult with major depressive disorder has not had a satisfactory response to, or could not tolerate, antidepressant treatment in the current episode, and is stable enough for daily outpatient care. Hold the referral, or refer to a higher level of care first, when there is acute suicidal risk, psychosis, an unclear bipolar history, a seizure disorder or an implanted device near the head. The referral moves fastest when it arrives with a medication-trial history, dates of psychotherapy, a baseline rating-scale score and the medical details that affect safety.

This guide is written for therapists, primary care physicians and psychiatrists. It covers depression, the indication with the strongest evidence; TMS for most other conditions is off-label or research-stage, and those uses are covered elsewhere in the TMS guide.

Who is a good referral

The NeuroStar label, for example, describes adults "who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode." Professional guidance is broadly aligned. The Clinical TMS Society recommends that TMS "should be considered" when antidepressants have not provided satisfactory benefit or when intolerance precludes their use. CANMAT 2023 rates rTMS as first line for treatment-resistant depression, typically after first-line psychotherapy and medication have failed, and adds that it can be a first-choice treatment when medication tolerability is a concern or when TMS helped in a previous episode.

Patients who tend to be good candidates:

• Adults with unipolar major depression, moderate to severe, who have had at least one or two adequate antidepressant trials without enough benefit.
• Patients who stopped antidepressants because of side effects such as sexual dysfunction, weight gain or sedation.
• Patients who responded to TMS in a past episode and have relapsed.
• Patients who are engaged in therapy and can attend frequent sessions for several weeks.
• Older adults for whom medication interactions or side effects are a concern, provided seizure risk factors and implants have been checked.

Adolescents are a narrower group. Several devices are now FDA-cleared as an adjunct for major depression at ages 15 to 21, but the only large sham-controlled adolescent trial of standard 10 Hz TMS was negative, and New York Medicaid covers only adults.

Safety flags: when to pause or redirect

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.

Medications are not usually a barrier. IFCN 2021 notes that most TMS patients take CNS-active medications and that the observed seizure rate is extremely low, though it still recommends documenting them. The full safety picture is in TMS safety and seizure risk, and the medical conditions worth excluding first are in ruling out medical causes before TMS.

Insurance criteria at a glance

Coverage often decides timing, so it helps to know what each plan will ask for. The main New York policies differ in ways that change what a referral needs to document:

Two practical points follow. First, the psychotherapy trial matters for Medicare and Cigna, so a therapist's dated summary of the modality, frequency and response is valuable evidence. Second, the Aetna, Cigna and Optum policies cover standard daily courses but treat accelerated protocols as experimental or unproven, even though some accelerated protocols are now FDA-cleared; that is worth knowing before a patient arrives asking for a five-day course. Plan-by-plan detail is in the guides to Medicare, NY Medicaid, Aetna, Cigna and UnitedHealthcare and Optum.

Records that make a referral useful

Payer forms ask for very similar information. Aetna, for example, wants medication names, doses and durations plus a baseline score on a validated scale, and Carelon's form asks for a medication table with dates and any TMS or ECT in the past three years with the response. A strong referral packet contains:

1. Diagnosis, with episode type and severity. Medicare and Optum cover TMS under the codes for severe major depression without psychotic features, single episode or recurrent.
2. A medication table: each antidepressant and augmenting agent, dose, start and stop dates, and why it was stopped (no response, partial response, side effects).
3. Psychotherapy history: modality, frequency, dates and response, ideally with scale scores.
4. A recent baseline score on a validated scale such as the PHQ-9, BDI, HAM-D or MADRS, and which scale you use.
5. Prior ECT, ketamine, esketamine or TMS, with dates and response.
6. Medical history relevant to safety: seizures, head injury, neurologic disease, implants and devices, cardiac history, pregnancy status, alcohol and substance use.
7. Current medication list, including sleep aids, stimulants and supplements.
8. Your most recent risk assessment and any safety plan.

What a TMS course asks of the patient

Patients do better when they know the commitment in advance. A standard course on the NeuroStar label is 5 days a week for 6 weeks followed by a 3-week taper, 36 sessions in all, and consensus guidance tells patients to expect 20 to 30 sessions over about six weeks to match trial results. The first visit includes motor-threshold mapping, which sets the dose for the rest of the course.

Expectations should be honest. In sham-controlled trials the gap in remission between active and sham TMS is typically about 9 to 18 percentage points, and sham groups often improve substantially. Open-label registry figures are higher but are mostly self-reported and partly from completers. Among people who respond, roughly half to about 6 in 10 are still doing well at one year in follow-up studies. These are not reasons to hold back a referral, but they are worth saying out loud.

Communication during the course

A referral should not end at the handoff. The Clinical TMS Society consensus strongly encourages repeated ratings with mood scales and says the TMS operator should provide updates or progress notes every day, monitored by the prescribing physician. Referring clinicians can reasonably ask for:

• Confirmation of the start date and the planned schedule.
• Rating-scale scores at baseline, around the midpoint and at the end of the acute course.
• Prompt notice of adverse events, emerging hypomania, worsening mood or new suicidal thinking.
• Coordination before any medication change. The same consensus says any medication change during the course "should prompt consideration for reassessment of the patient's motor threshold."
• An end-of-course summary with the final score, the taper plan and who follows the patient afterward.

Therapy usually continues during TMS, and the therapist is often the first to notice change. A short weekly check-in between the therapist and the TMS team keeps everyone working from the same picture. Why a physician should own these decisions is covered in who delivers TMS and why oversight matters.

After the course: relapse and retreatment

Agree on a relapse plan before the course ends. The Clinical TMS Society recommends that if relapse follows a good response, TMS "should be reintroduced until remission is re-achieved." Payers set conditions: New York Medicare allows retreatment after relapse when the earlier course produced more than 50% improvement on a standard scale, and Aetna requires that the earlier response lasted at least two months and that the new course start more than 60 days after the last one. Maintenance TMS is not covered by Medicare and is listed as experimental by Aetna. Keeping rating-scale records during and after the course makes a later retreatment request far easier.

How to send a referral

For psychiatric evaluation at Dr. Lewis's practice, the referral page explains how to send a patient's details. A patient who wants to raise TMS with their own psychiatrist first may find how to bring up TMS with your psychiatrist or therapist helpful. The practice's current TMS information is on the TMS therapy page.

Frequently asked questions

How many antidepressants should a patient have tried before I refer for TMS?

FDA-cleared labeling such as NeuroStar's refers to failure of prior antidepressant treatment in the current episode, and guidelines support TMS after one or more adequate trials. Insurers usually want two, often from different classes, so document every trial with dose and duration.

Can a therapist refer directly for TMS?

A therapist can refer the patient for evaluation, but a physician or, under some policies, a psychiatric nurse practitioner must order the treatment. The therapist's dated psychotherapy summary is often part of the insurance evidence.

Should my patient stop their antidepressant before TMS?

Not as a rule. Many patients continue medication during TMS. Any change should be coordinated with the TMS physician, because medication changes can affect the motor threshold used to set the dose.

Is TMS appropriate for a patient with passive suicidal thoughts?

Often yes, after a careful risk assessment and with a safety plan in place. Active intent, a plan or a recent attempt calls for a higher level of care first.

What should I expect to hear back during the course?

Reasonable expectations are a start date, rating-scale scores at baseline, midpoint and end, prompt notice of adverse events or worsening, and an end-of-course summary with a relapse plan.

Sources

1. FDA 510(k) K160703 and K161519 (NeuroStar). U.S. FDA, 2016. accessdata.fda.gov
2. The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation, 2016. pmc.ncbi.nlm.nih.gov
3. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Canadian Journal of Psychiatry, 2024. pmc.ncbi.nlm.nih.gov
4. 510(k) Premarket Notification database (adolescent MDD labels). U.S. FDA, 2026. accessdata.fda.gov
5. Left prefrontal transcranial magnetic stimulation for treatment-resistant depression in adolescents: a double-blind, randomized, sham-controlled trial. Neuropsychopharmacology, 2021. pubmed.ncbi.nlm.nih.gov
6. Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry, 2018. pmc.ncbi.nlm.nih.gov
7. Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. FDA, 2011. fda.gov
8. Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 2021. europepmc.org
9. LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal via CMS Medicare Coverage Database, 2026. cms.gov
10. Billing and Coding: Transcranial Magnetic Stimulation (A57528). Wellpoint Federal via CMS Medicare Coverage Database, 2026. cms.gov
11. New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (Medicaid Update, July 2025). NYS Department of Health, 2025. healthweb-back.health.ny.gov
12. Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
13. Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
14. Behavioral Clinical Policy: Transcranial Magnetic Stimulation. Optum Behavioral Health Solutions, 2026. providerexpress.com
15. Carelon Behavioral Health Repetitive Transcranial Magnetic Stimulation Request Form (commercial contracts). Carelon Behavioral Health, undated. carelonbehavioralhealth.com
16. K231926 510(k) Summary: NeuroStar Advanced Therapy System. U.S. FDA, 2024. accessdata.fda.gov
17. Clinical outcomes in a large registry of patients with major depressive disorder treated with Transcranial Magnetic Stimulation. Journal of Affective Disorders, 2020. pubmed.ncbi.nlm.nih.gov
18. Durability of antidepressant response to repetitive transcranial magnetic stimulation: Systematic review and meta-analysis. Brain Stimulation, 2019. pubmed.ncbi.nlm.nih.gov
19. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Archives of General Psychiatry, 2010. pubmed.ncbi.nlm.nih.gov
20. Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry, 2015. pmc.ncbi.nlm.nih.gov
21. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: durability of benefit over a 1-year follow-up period. Journal of Clinical Psychiatry, 2014. pubmed.ncbi.nlm.nih.gov
22. K260189 510(k) Summary - MagVenture Accelerated TMS (aTMS) Therapy System. U.S. FDA, 2026. accessdata.fda.gov

Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.