General plan covers TMS, but not MY plan?

Hello all,

I found this sub and I've been struggling with this recently so thought I'd see if this group had any insight on it. I need to get coverage for a series of transcranial magnetic stimulation (TMS) treatments. It's billed under codes 80867, 80868, and 80869. Right now, I have a Blue Cross Blue Shield of Michigan policy through my work. I'm 34FTM (F legally), zip code is 55311. My policy is in Michigan due to my work HQ's location, while I live in Minnesota (which isn't helping).

According to their policy posted online (and comments from phone calls), they cover TMS. But apparently my specific plan, as in the one my workplace has, doesn't cover it. I dug through the riders and such and I can't seem to find any exclusions besides the standard experimental treatment one (which I know is why they won't cover maintenance TMS).

Does anyone have any ideas why my specific policy doesn't cover these codes? Even just knowing why it's exempted from coverage could be helpful. Everyone I've called is just reading off their screen and then shrugging.

Also, assuming they don't cover it, what are other pathways to this treatment? My clinic says they'll work on an appeal, but I'm not super hopeful about it and I'm curious if I have any other options. Otherwise, I'll likely end up having to wait until January, and that will be…very not great for my mental health.

Thanks in advance!

submitted by /u/chickadee_23
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