UnitedHealthcare and Optum TMS Coverage: The Criteria, Policy by Policy
For UnitedHealthcare members, TMS for depression is not decided under a UnitedHealthcare medical policy at all. UnitedHealthcare's commercial TMS policy covers only physical-health uses and sends every behavioral request to Optum's Behavioral Clinical Policy, "Transcranial Magnetic Stimulation", policy BH803TMS112025. That Optum policy was last reviewed annually on 11/18/2025, with an interim review on 04/21/2026, and it covers people 15 and older with severe major depression after two failed or poorly tolerated medication trials, for up to 30 sessions plus 6 tapering sessions.
Optum does not require a failed psychotherapy trial, which sets it apart from Medicare and Cigna. It does treat theta burst, accelerated protocols and maintenance TMS as unproven. Policies are revised often, so confirm the current version with your plan before treatment starts.
Which document applies to your UnitedHealthcare plan
UnitedHealthcare sells several kinds of coverage in New York, and each one points to a different TMS document. Start by finding your plan type on your member ID card, then use the table below.
| Your coverage | Document that sets TMS criteria | Status as of 7 October 2026 |
|---|---|---|
| UnitedHealthcare commercial (employer) or individual exchange plan | Optum Behavioral Clinical Policy BH803TMS112025, reached through UnitedHealthcare policy 2026T0536W | Published; Optum says it applies "to all lines of business unless superseded by federal or state regulations" |
| Oxford (UnitedHealthcare Oxford, NY/NJ/CT) | No Oxford-specific TMS policy could be retrieved | The Oxford policy link returned an error; ask Oxford which policy it uses |
| UnitedHealthcare Medicare Advantage with Optum behavioral health | Optum Medicare Coverage Summary BH803MCSTMS092025, which reproduces Medicare's New York rules (LCD L33398) | Published |
| UnitedHealthcare Community Plan (NY Medicaid, Child Health Plus; Essential Plan from November 1, 2026) | Optum New York supplemental criteria BH803NYTMS122025, which apply the New York State Medicaid criteria | Published |
The table draws on the policy numbers and revision dates in each document. The Oxford row matters for many New York employer plans. The Oxford-specific TMS policy address returned a "not found" page on 7 October 2026, and the assumption that Optum's behavioral policy governs Oxford members is an inference from UnitedHealthcare and Optum documents, not an Oxford statement. If you are an Oxford member, ask for the policy name and number in writing.
New York City employees deserve a separate note. Since January 1, 2026 the city's NYCE PPO, offered jointly by UnitedHealthcare and EmblemHealth, has used the United Behavioral Health network operating under the Optum brand, including in the downstate counties. Which TMS criteria that plan applies is covered in the EmblemHealth, GHI and NYC employee guide.
Optum's commercial criteria, requirement by requirement
The Optum policy reads as a checklist. Each row below is a point a TMS team must document before a request goes in.
| Requirement | What BH803TMS112025 says | What the record needs to show |
|---|---|---|
| Age | 15 and older from 01/01/2026 (18 and older before that date) | Date of birth; for ages 15 to 17, the adolescent rules below |
| Diagnosis | Major depressive disorder coded F32.2 or F33.2 (severe, without psychotic features) | A diagnostic assessment and a baseline score on a validated scale such as the BDI, HAM-D or MADRS |
| Medication trials, adults | No clinically significant response to, or inability to tolerate, two evidence-based medication regimen trials in the current episode, from at least two different classes | Drug names, doses, start and stop dates, and the reason each trial ended |
| Medication trials, ages 15 to 17 | Two regimen trials; no class requirement stated | The same trial details |
| Psychotherapy | Not required; removed in the 02/21/2023 revision | Therapy history is still useful clinical context |
| Device | Must be FDA-cleared for MDD (Optum's text says "FDA-approved") | Device name |
| Who orders and supervises | A qualified psychiatrist, or a psychiatric mental health nurse practitioner in a full-practice-authority state; New York is on Optum's list | Ordering clinician's credentials |
| Course length | Up to 30 treatment sessions, followed by 6 tapered treatments | Treatment plan |
| Safety work-up | Motor threshold before treatment and a suicide-risk assessment at admission | Both recorded in the chart |
Each row is quoted or paraphrased from the Optum policy and its full-practice-authority state list, revised 03/17/2026. Two details trip up requests. First, intolerance counts as well as non-response, so a drug stopped for side effects belongs in the history with the reason recorded. Second, the listed codes describe severe depression; a chart that describes the episode as moderate does not match them.
Medicare and Cigna both require a failed psychotherapy trial, so a patient who never had structured therapy may meet Optum's criteria and not theirs. For how a "failed trial" is judged clinically, see what STAR*D tells us about treatment resistance.
What Optum lists as unproven or not medically necessary
Optum's exclusion list is broader than most. It names these treatments and situations:
- Maintenance or booster TMS after a completed course.
- Accelerated TMS protocols and theta burst stimulation protocols.
- Navigated TMS.
- TMS during pregnancy or while nursing.
- Acute suicidality, psychosis or other psychiatric emergencies.
- Indications other than major depression, including depression at 14 and younger, bipolar disorder, OCD, PTSD, psychotic disorders, autism, dementia and smoking cessation.
UnitedHealthcare's own medical policy, effective 02/01/2026, likewise lists "theta-burst stimulation, including accelerated and/or magnetic resonance imaging-guided protocols" as unproven. That puts the payer at odds with some clinical guidance. The CANMAT 2023 guideline rates intermittent theta burst to the left prefrontal cortex as a first-line protocol with Level 1 evidence. A coverage policy is a payment rule, not a verdict on the science. The evidence is covered in theta burst stimulation explained and accelerated TMS and its FDA status.
The exclusion for acute suicidality reflects clinical practice as well as payment: a person in immediate danger needs faster care than a six-week course. 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.
Retreatment after a relapse
Optum allows a second course, but under narrow terms. Since 01/01/2024, retreatment "may be considered for members that have relapsed 6 months after the most recent treatment", provided the person met the initial criteria, relapsed despite ongoing treatment, and improved by more than 50% during the earlier course.
In practice, that means rating-scale scores from the first course become evidence for the second, so keep copies. Because maintenance sessions are excluded, a relapse prevention plan usually relies on medication, therapy and monitoring rather than scheduled TMS. Durability data are summarized in how long TMS results last, and response versus remission explains what a 50% improvement means on a rating scale.
How Optum compares with other New York payers
| Payer and policy | Medication failures | Psychotherapy trial | Minimum age | Theta burst |
|---|---|---|---|---|
| UnitedHealthcare / Optum, BH803TMS112025 | Two regimens, two classes (adults) | No | 15 | Unproven |
| Aetna, CPB 0469 | Two drugs, two classes, 8 weeks each, plus 8 weeks of augmentation (adults) | No (adults) | 15 | iTBS covered on an FDA-cleared device |
| Cigna / Evernorth, EN0383 | Two or more trials, two classes, 4 weeks each (adults) | Yes | 15 | Experimental |
| Medicare in New York, LCD L33398 | One trial with agents from two classes, or other routes | Yes | Adults | Not addressed |
The comparison is drawn from each policy's current text. The details for each payer are in the guides to Aetna, Cigna and Medicare in New York.
Medicare Advantage and Community Plan members
A UnitedHealthcare Medicare Advantage plan cannot simply apply Optum's commercial rules. Under the 2024 Medicare Advantage rule, plans "must comply with" national and local coverage determinations and may use internal criteria only when coverage criteria are "not fully established". Optum's Medicare Coverage Summary for TMS reproduces the New York LCD criteria, which include a failed psychotherapy trial; that summary still contains a supervision sentence that Medicare removed on 08/09/2026, so the LCD itself is the controlling text.
For UnitedHealthcare Community Plan members on Medicaid, Child Health Plus or the Essential Plan, Optum applies the New York State Medicaid TMS criteria verbatim. New York Medicaid defines treatment resistance as "two trials of a therapeutic dose of two different antidepressants for a sufficient duration" and covers adults 18 and older. Optum extends the same criteria to the Essential Plan effective November 1, 2026. The state rules are explained in New York Medicaid TMS coverage.
What is not published, and how to get it
Several practical questions have no public answer for UnitedHealthcare and Optum. Whether Optum requires prior authorization for TMS on commercial plans was not verified in a public document, and the Oxford-specific policy could not be retrieved. Out-of-network benefits and cost sharing vary by employer plan.
New York law gives you a way to get the criteria. Insurers covering group mental health benefits must make their medical-necessity criteria available to insureds, prospective insureds and in-network providers on request. For state-regulated plans, a preauthorization decision is due within three business days of receiving the necessary information. Call the behavioral health number on your card and ask:
- Which TMS policy, by name and number, applies to my plan, and what is its current revision date?
- Is prior authorization required, and who submits it?
- How many sessions are authorized at first, and how are the tapering sessions handled?
- Do I have out-of-network benefits for TMS, and at what coinsurance and deductible?
- Is my plan fully insured or self-funded by my employer?
The last question decides which appeal and parity rules apply, as explained in how New York parity law applies to TMS claims. If a request is denied, the patient-side steps are laid out in how to appeal a TMS denial in New York.
Where this fits
Insurance criteria tell you whether a plan will pay, not whether TMS is the right next step. That decision belongs with a psychiatrist who knows your history. More on the treatment itself is in the physician's guide to TMS, and the TMS service page explains how a psychiatrist evaluates whether TMS fits.
Frequently asked questions
Does UnitedHealthcare require therapy before covering TMS?
Not under Optum's current behavioral policy. Optum removed its psychotherapy requirement in February 2023. Medicare Advantage plans follow Medicare's New York rules, which do require a psychotherapy trial.
Will UnitedHealthcare cover SAINT or accelerated TMS?
Both Optum's behavioral policy and UnitedHealthcare's medical policy list accelerated and theta burst protocols as unproven, so a standard request is unlikely to be approved. Confirm the current policy before paying out of pocket.
Can a 16-year-old get TMS covered by UnitedHealthcare?
Optum's policy has covered ages 15 and older since January 1, 2026, after two medication regimen trials. Depression at 14 and younger is listed as unproven.
Is Oxford's TMS policy the same as UnitedHealthcare's?
An Oxford-specific TMS policy could not be retrieved in October 2026. UnitedHealthcare routes behavioral TMS to Optum's policy, but Oxford has not confirmed that in a public document, so ask Oxford for the policy name and number.
How soon after a first course can I get a second one covered?
Optum considers retreatment for relapse 6 months after the most recent treatment, when the first course produced more than 50% improvement and the initial criteria were met.
Sources
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation (BH803TMS112025). Optum Behavioral Health Solutions, 2026. providerexpress.com
- Transcranial Magnetic Stimulation for Treating Physical Health Conditions (2026T0536W). UnitedHealthcare, 2026. uhcprovider.com
- Transcranial Magnetic Stimulation: Full Practice Authority Nurse Practitioner States (BH803TMSLIC32026). Optum Behavioral Health Solutions, 2026. providerexpress.com
- Optum Medicare Coverage Summary: Transcranial Magnetic Stimulation (BH803MCSTMS092025). Optum Behavioral Health Solutions, 2025. providerexpress.com
- New York Medicaid and Essential Plan: Transcranial Magnetic Stimulation (BH803NYTMS122025). Optum Behavioral Health Solutions, 2026. providerexpress.com
- New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (Medicaid Update Vol. 41 No. 7). NYS Department of Health, 2025. healthweb-back.health.ny.gov
- LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal via CMS Medicare Coverage Database, 2026. cms.gov
- 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) fact sheet. CMS, 2023. cms.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (CPB 0469). Aetna, 2026. aetna.com
- Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
- NY Insurance Law Sec. 3221 (group mental health coverage). New York State Senate, 2026. nysenate.gov
- NY Insurance Law Sec. 4903 (Utilization review determinations). New York State Senate, 2026. nysenate.gov
- 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
- City of New York Employees (NYCE) PPO plan: Frequently asked questions (PCA-1-26-00070-E&I-FAQ_01292026). UnitedHealthcare, 2026. uhcprovider.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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