RSLNT Wellness has submitted 1,800+ TMS prior auths across 12 payers since 2024. Our approval rate started at 67%. It's at 89% today. This post is what changed.
Why prior auths get denied (the boring answer)
We pulled every denial letter we'd received over 18 months and tagged them by reason. Three reasons accounted for 81% of denials.
- TRD criteria not explicitly cited (one or more of the failed-trial requirements)
- Outcome score not at the right threshold or not from a recognized scale
- Treatment plan rationale missing the magic word ('medical necessity' phrased a specific way)
All three are documentation problems, not clinical problems. Every patient denied for these reasons clinically qualified. The packet didn't say so clearly enough for the reviewer.
The four sentences that fixed most of them
We restructured every prior-auth template around four sentences in this order. We require all four to be present and specific.
- TRD diagnosis — explicit. ("Patient meets DSM-5 criteria for Major Depressive Disorder, recurrent, severe, currently in episode lasting [X] weeks.")
- Failed trials — enumerated with dates and durations. ("Patient has failed adequate trials of: [drug] [dose] [duration], [drug] [dose] [duration], [drug] [dose] [duration].")
- Outcome score — current and trend. ("Current PHQ-9: [X]. MADRS: [X]. Both reflect severe depression unresponsive to standard pharmacologic intervention.")
- Medical necessity — the magic phrase. ("TMS is medically necessary as the patient meets all criteria for treatment-resistant depression and has failed standard-of-care pharmacologic treatment.")
What changed in the data
We rolled the new template out in Q3 of last year. Approval rate by quarter:
- Q2 2024 (old template): 67%
- Q3 2024 (new template, partial rollout): 78%
- Q4 2024 (new template, full rollout): 86%
- Q1 2025: 89%
- Q2 2025: 89%
What payers we still struggle with
Two patterns to flag.
First, regional BCBS plans are wildly inconsistent. The same packet that gets approved in one state denies in another. We keep state-specific notes in our template now.
Second, Medicaid plans typically require an additional letter from the supervising psychiatrist explicitly attesting medical necessity, separate from the prior-auth packet. This isn't documented anywhere in their published criteria — we learned it from denied claims. We now generate the letter automatically when a Medicaid plan is selected.
How to use this in your clinic this week
- Pull your last 20 denied prior auths.
- Tag them by reason. Bet you'll see the same three patterns we did.
- Update your template to require the four sentences above.
- Re-submit the rejectable ones with the new packet.
If you're using Heepsters Practice for TMS, this template is what we ship by default. The chart auto-fills the trial history, the outcome scores, and the magic phrase. The whole packet generates in about 12 minutes.