# Meet Dr. Padmini Shamasundara: Why We Built a TMS-First Practice Healing TMS Clinic exists because conventional outpatient psychiatry, as it is structured in most communities, does not handle treatment-resistant depression and refractory OCD well. The patient who has cycled through several antidepressants without sustained response is often referred outward — to a separate TMS provider, a separate insurance workup, a separate clinical narrative — and the coordination that should be the most important part of their care becomes the part most likely to break. Dr. Padmini Shamasundara has practiced psychiatry for more than 27 years. The decision to build a **TMS-first practice** in Anaheim was a clinical decision, made in response to a pattern she saw repeatedly: the patients who most needed neuromodulation were the patients least able to navigate the hand-offs required to access it. This article is a short introduction to the psychiatrist behind Healing TMS Clinic, the clinical model the practice operates under, and what that model means for a patient walking in for a first evaluation. ## Clinical background Dr. Shamasundara completed her medical degree in 1985 and her psychiatry residency between July 1991 and June 1995. She holds an active California medical license and active DEA registration, and has been in continuous psychiatric practice for more than 27 years. Her clinical interest in **neuromodulation and non-pharmacologic approaches that complement standard pharmacotherapy** has shaped the practice she now leads — a focus that predates the current breadth of FDA-cleared TMS indications and reflects a sustained orientation toward evidence-based alternatives to indefinite medication escalation. A fuller background and statement of clinical approach is available on her [physician profile](/team/dr-shamasundara/). ## Areas of focus Dr. Shamasundara's clinical focus areas are: - **Treatment-resistant depression** and major depressive disorder - **Obsessive-compulsive disorder** (specialty focus) - **Post-traumatic stress disorder** (specialty focus) - **Generalized anxiety, panic, and social anxiety disorders** - **Sleep disorders and insomnia** in the context of psychiatric illness - Psychopharmacology, with attention to minimizing reliance on long-term antidepressant or anxiolytic regimens where a non-pharmacologic alternative is clinically indicated This list reflects where her practice's referrals concentrate. The condition mix — depression, OCD, PTSD, anxiety — overlaps substantially with the FDA-cleared and evidence-based indications for [transcranial magnetic stimulation](/services/tms-therapy/), which is part of why a TMS-first practice fits the caseload rather than reshaping it. ## How the practice works The clinical model that defines the practice has three components, each of which exists to remove a specific failure mode that fragmented outpatient psychiatry tends to introduce. ### 1. Coordinated medication management and TMS in one practice The treating psychiatrist who knows the patient's diagnostic history, prior medication trials, and treatment goals is the same psychiatrist who evaluates candidacy for TMS, signs the **letter of medical necessity** for prior authorization, selects the protocol, and adjusts it mid-course if the response trajectory calls for it. There is no referral hand-off between a prescribing psychiatrist and a separate TMS provider, and no parallel clinical record to reconcile. Where a course of TMS is followed by adjustment to a concurrent medication regimen, both decisions are made by the same clinician. ### 2. Course-by-course device selection across multiple FDA-cleared systems The clinic operates a fleet of three FDA-cleared TMS systems — **Brain Ultimate M Series**, **Sabers Medical Blossom**, and **BrainsWay Deep TMS**. Each system has different coil geometry, different cleared indications, and different protocol options. Device selection is made by Dr. Shamasundara on a course-by-course basis — that is, the device is chosen for the patient's indication and protocol, rather than the indication being forced into whatever device the clinic happens to own. A clinic with a single device must work within that device's protocol library; a clinic with three has additional optionality at the moment when optionality matters most — the start of a course. ### 3. In-house insurance team handling prior authorization end-to-end [Insurance verification](/insurance/verify/), prior authorization, and continued-treatment requests are handled by a clinic team rather than passed back to the patient or the referring provider. The prescribing psychiatrist signs the medical-necessity documentation directly; the insurance team carries it through submission, peer-to-peer review where required, and any appeals workflow. Prior-authorization decision timelines for commercial coverage typically run 5 to 15 business days; Medicare Advantage, Medicaid, and Federally-Facilitated Exchange QHP coverage operates under a 7-day standard / 72-hour expedited framework under **CMS-0057-F**, effective in 2026.[^cms-0057-f] The in-house workup is built around those timelines. ## What this means for patients For a patient walking in for a first evaluation, the practical implications are specific: - **The treating psychiatrist signs the prior-authorization letter.** Not a referring provider, and not a clinical coordinator working from forwarded chart notes. The clinician who recommended TMS is the clinician on record with the carrier. - **Adjustments mid-course are made by the same clinician who knows the patient.** A protocol change from standard 10 Hz rTMS to intermittent theta-burst stimulation, a coil-position remap, a dose modification, or a concurrent medication adjustment is a same-practice decision rather than a multi-party negotiation. - **The clinic accepts new patients for general psychiatric consultations, medication management, and TMS evaluations.** Not every patient who walks in is a TMS candidate, and not every TMS evaluation results in a recommendation to proceed. The practice is structured as a full psychiatric practice with a TMS-first orientation, not a procedural clinic. ### A typical clinical scenario A patient with major depressive disorder who has completed adequate trials of three SSRIs and one SNRI without sustained response — adequate meaning therapeutic dose for at least six weeks per trial — is the standard candidate for the TMS conversation in this practice. The conversation is not framed as a last resort but as the next evidence-based step: under contemporary CMS and commercial medical-necessity criteria, this trial history is precisely the documentation that supports prior authorization for TMS for treatment-resistant depression.[^cms-tms] The Clinical TMS Society consensus continues to serve as the device-agnostic reference for parameter selection in such cases.[^perera-2016] The same patient, evaluated in a fragmented care environment, would typically be referred to a separate TMS provider with a new intake, a new medical-necessity workup, and a new clinical relationship. In a TMS-first practice, the trial history is already in the chart, the candidacy assessment is the next appointment, and the prior-authorization packet is assembled from records the clinic already holds. This scenario is illustrative, not a description of any individual patient. ## Key takeaways - **Healing TMS Clinic is a TMS-first psychiatric practice in Anaheim**, structured around the patients for whom medication management alone has been insufficient. - **Dr. Padmini Shamasundara** has practiced psychiatry for more than 27 years (medical degree 1985; psychiatry residency 1991–1995), with a sustained focus on neuromodulation and non-pharmacologic approaches that complement pharmacotherapy. - **The clinical model keeps medication management, device selection across three FDA-cleared TMS systems, and the prior-authorization workup inside one practice** — removing the hand-offs where fragmented outpatient care most often breaks. - **The clinic is accepting new patients** for general psychiatric consultations, medication management, and TMS evaluations at the Anaheim office. ## Closing Patients in Anaheim and across Orange County considering a psychiatric consultation, a second opinion on a refractory depression or OCD presentation, or a candidacy evaluation for TMS can begin by reviewing Dr. Shamasundara's [physician profile](/team/dr-shamasundara/) and the clinic's approach to [TMS therapy](/services/tms-therapy/). Most patients start with an [insurance verification](/insurance/verify/) so the coverage picture is clear before the clinical conversation about candidacy and protocol. ## Sources / Further reading [^cms-0057-f]: Centers for Medicare & Medicaid Services. Final Rule CMS-0057-F, *Advancing Interoperability and Improving Prior Authorization Processes*, effective 2026 — establishing 7-day standard and 72-hour expedited prior-authorization decision timeframes for Medicare Advantage, Medicaid, CHIP, and Federally-Facilitated Exchange QHP issuers. [^cms-tms]: Centers for Medicare & Medicaid Services. Local Coverage Determinations (LCDs) governing transcranial magnetic stimulation for major depressive disorder. Coverage is administered through MAC-level LCDs rather than a National Coverage Determination. [^perera-2016]: Perera T, George MS, Grammer G, Janicak PG, Pascual-Leone A, Wirecki TS. The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. *Brain Stimulation*. 2016;9(3):336–346.