TMS denied as not medically necessary by Cigna?

Cigna's specific coverage criteria for tms are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Cigna Denies TMS as Not Medically Necessary

Transcranial Magnetic Stimulation (TMS) is an FDA-cleared, non-invasive neuromodulation procedure used primarily for Major Depressive Disorder (MDD) that has not responded to prior antidepressant treatment. Cigna's medical-necessity denials for TMS almost always hinge on whether your documented treatment history satisfies their published coverage criteria — specifically, the number and adequacy of prior antidepressant medication trials. Insurers require that chart documentation clearly establishes that those prior treatments failed despite adequate dosing and duration, not merely that they were tried.

## Your Appeal Rights

Federal law gives you strong appeal protections. Under ACA §2719 and ERISA §503, you are entitled to a full internal appeal followed by an independent external review if the internal appeal is denied. The external review must be completed by an accredited, independent review organization — not Cigna. You generally have approximately 180 days from the denial to file your internal appeal, and you must exhaust internal appeals before accessing external review. If your situation is urgent (for example, a significant worsening of depression or a documented safety concern), you may request an expedited review with a faster turnaround.

## What to Gather

• Diagnosis confirmation: Psychiatrist or treating clinician's documented diagnosis of MDD (or the specific condition for which TMS is prescribed), including severity rating using a validated scale from your chart.
• Prior treatment history: A complete list of antidepressant medication trials with start/stop dates, doses prescribed, duration, and documented outcomes or reasons for discontinuation.
• Clinical severity: Chart notes establishing current symptom burden — your clinician's narrative and objective assessment tools on file.
• Prescriber medical-necessity letter: A detailed letter from your psychiatrist or referring physician explaining why TMS is medically necessary for you specifically, why remaining medication options are not appropriate, and how your case meets the coverage criteria in Cigna's own policy.

## Criteria-Mapping Structure

Obtain a copy of Cigna's current coverage policy for TMS (request it directly from Cigna). List every requirement they state. For each requirement, document the specific chart evidence that satisfies it. For example:

| Cigna Criterion | Your Supporting Evidence | |---|---| | Diagnosis of MDD confirmed | [Date of diagnosis in chart, clinician name] | | Minimum number of adequate prior antidepressant trials | [List each medication, dates, duration, outcome] | | Trials at adequate dose/duration | [Chart documentation per trial] | | No contraindication per prescriber assessment | [Prescriber attestation in letter] |

Cross-referencing your chart facts against the exact language of Cigna's policy — not a paraphrase of it — is the most effective way to rebut a medical-necessity denial.