# The First 90 Days at Healing TMS: Our Onboarding Pathway The first 90 days at Healing TMS Clinic typically span three phases: **Week 0 — inquiry and pre-treatment** (initial contact, candidacy questionnaire, evaluation appointment, insurance verification, prior authorization); **Weeks 1-6 — acute treatment** (motor-threshold mapping at session 1, then approximately 30 weekday sessions over six weeks); and **Weeks 7-9 — taper and the decision about maintenance.** The full timeline runs roughly nine to twelve weeks from the patient's first call to the end of the taper. This article walks the pathway step by step — what the clinic does, what the patient does, and where the workflow becomes opaque without explanation. It is written equally for prospective patients trying to understand what comes next and for referring providers who want to see how an external referral moves through the practice before sending one. ## Week 0 — inquiry and pre-treatment The most opaque part of TMS for most patients is the stretch between the first phone call and the first treatment session. Week 0 covers that interval. In a typical commercial-insurance case it runs one to three weeks; in a Medicare Advantage or marketplace case under CMS-0057-F it can be shorter. ### Initial contact A patient enters the pathway one of three ways: through the [TMS questionnaire](/tms-questionnaire) on the clinic website, by phone, or via a referral from a treating psychiatrist, primary-care physician, or therapist. The questionnaire is a short screening instrument — diagnosis, current episode, prior antidepressant trials, contraindication flags — that the clinical team reviews before scheduling. Referring-provider referrals can be made directly to the clinic by phone or secure fax; a treatment summary letter is not required at the inquiry stage. ### Pre-screening review The clinical team reviews the questionnaire or referring-provider summary against the candidacy criteria that determine whether a full evaluation is appropriate: a working DSM-5-TR diagnosis of major depressive disorder, documented prior antidepressant trials in the current episode, no obvious contraindications (personal history of seizure disorder, ferromagnetic implants within approximately 30 cm of the treatment coil, certain implanted neurostimulation devices), and a baseline rating-scale severity consistent with at least moderate depression. Patients who clearly do not meet candidacy are told so at this stage rather than after an evaluation; patients who meet the screening threshold are scheduled for a full evaluation appointment. ### Evaluation appointment The evaluation appointment with the treating psychiatrist runs **60 to 90 minutes** and serves three purposes: confirming the diagnosis and the current episode, documenting the medication-trial history that establishes treatment resistance, and ruling out contraindications. PHQ-9 and other validated rating scales are administered at baseline; subsequent scores will be measured against this number to document response. The treating psychiatrist also reviews the patient's other care — current pharmacotherapy, psychotherapy, and any specialty providers — so the TMS course can be coordinated with the rest of the treatment plan rather than running in parallel to it. ### Insurance verification and prior authorization [Insurance verification](/insurance/verify/) runs alongside the evaluation, not after it. The clinic's insurance coordinator confirms benefits, copay structure, and the specific prior-authorization criteria the patient's plan requires. The prior-authorization packet — PHQ-9 scores, medication-trial log, treatment-history letter from the treating psychiatrist, treatment plan, and statement of candidacy — is then submitted. Commercial prior-auth turnaround typically runs **5 to 15 business days**; Medicare Advantage, Medicaid, and Federally-Facilitated Exchange QHPs follow a **7-day standard / 72-hour expedited** framework under CMS-0057-F.[^cms-0057-f] First-submission completeness is the single largest determinant of turnaround; the clinic's standard workflow is to submit a complete packet on the first pass rather than respond to a request for additional information. ## Week 1 — first treatment session Treatment begins as soon as the authorization is in hand and a consistent weekday slot is reserved. ### Motor-threshold mapping The first session includes a one-time procedure called **motor-threshold mapping** — the calibration step that determines the lowest stimulator output producing a visible thumb or finger twitch when the coil is positioned over the motor cortex. The individualized motor threshold (MT) is used to set treatment intensity, typically at 120% of MT, for the rest of the course.[^perera-2016] Mapping is performed once at the start of the course; it is not repeated at subsequent sessions. ### Time in the chair on day one Total chair time on day one is typically **60 to 90 minutes** — motor-threshold mapping plus the first treatment session plus a brief post-session check. Sessions 2 through 36 return to the protocol-standard runtime: approximately 10 to 20 minutes for intermittent theta-burst stimulation (iTBS) or approximately 40 minutes for standard 10 Hz repetitive TMS (rTMS). The choice of protocol is made by the treating psychiatrist based on tolerability, scheduling, and prior treatment history. ### No sedation, no driver TMS is delivered without sedation. Patients drive themselves to and from sessions and return to work, school, or normal activity immediately afterward.[^lerner-2019][^rossi-2021] No medication clearance, no fasting, and no driver are required. ## Weeks 1-4 — the acute phase The acute phase is the densest portion of the pathway. - **Five sessions per week, Monday through Friday.** Closely spaced sessions are mechanistic, not administrative; the cumulative cortical change that produces antidepressant response develops on a massed schedule and does not develop on weekly or sporadic schedules. - **Weekly PHQ-9.** The rating scale is administered weekly to document trajectory. PHQ-9 trajectory is what continued-treatment authorization decisions are based on later in the course; the weekly score is therefore both a clinical instrument and a documentation instrument. - **Brief check-ins.** If a patient reports new symptoms, tolerability concerns, or changes in other medications, the clinical team performs a brief check-in between sessions. The threshold for raising a concern with the team is low; small adjustments to coil position or intensity ramp are common in the first one to two weeks. - **Mid-course assessment at week 4.** The treating psychiatrist reviews the four-week PHQ-9 trajectory, tolerability, and any protocol adjustments. If response is on track, the course continues unchanged; if response is not yet emerging, the psychiatrist may adjust parameters or plan for an extended course. ## Weeks 4-6 — late acute phase Response to TMS is gradual and cumulative, not immediate. Most clinical-trial cohorts show measurable improvement starting around weeks two to four, with full response typically assessed at the end of the acute phase. Absence of measurable change by week four does not constitute treatment failure; the bulk of clinical response in routine practice is documented in the second half of the acute phase. The weekly PHQ-9 trajectory through weeks four to six is the clinical and administrative record that supports continued-treatment authorization if the course needs to extend beyond the initially approved session count. Toward the end of week six the treating psychiatrist discusses the taper schedule with the patient. ## Weeks 7-9 — taper and the maintenance decision After the acute phase, sessions step down rather than stopping abruptly. A common taper schedule reduces frequency over two to three weeks — for example, **three sessions in the first taper week, two in the second, and one in the third** — to consolidate response and reduce the early-relapse rate that has been described when treatment is stopped without a taper.[^perera-2016] The exact schedule is set by the treating psychiatrist based on the patient's response trajectory. A final PHQ-9 is documented at the end of the taper. The treating psychiatrist and patient then discuss the maintenance pathway. Three models are seen in routine practice: - **No maintenance** — sustained remission supported by routine medication management and psychotherapy alone. Appropriate for first-episode or low-recurrence patients with full remission at the end of the acute phase. - **Scheduled boosters** — a stepped-down booster calendar in patients with documented relapse history or incomplete remission. - **Symptom-triggered boosters** — no booster sessions are pre-scheduled; the patient returns at the first signs of recurrence, supported by self-monitored PHQ-9 and a low-friction re-entry pathway at the clinic. Maintenance is a separate authorization in most cases; the clinic's insurance team handles the continued-treatment submission when a maintenance model is selected. ## What stays consistent through all 90 days The onboarding pathway is designed so that the same people stay with the patient from inquiry through taper. - **The same prescribing psychiatrist** — Dr. Padmini Shamasundara — performs the evaluation, sets the treatment plan, signs the prior-authorization letter, oversees the acute course, and decides the taper and maintenance pathway. There is no hand-off mid-course. - **The same insurance coordinator** handles verification, prior authorization, continued-treatment authorization, and any appeal. The patient is not asked to repeat their story to a different person at each administrative step. - **Coordination with the patient's other providers** continues throughout the course. Medication management with the patient's prescribing psychiatrist (if external), psychotherapy with the patient's therapist, and primary-care or specialty follow-up (including OB care where relevant) continue unchanged. TMS supplements the existing treatment plan; it does not replace it. ## What the patient needs to do at each stage The clinical work belongs to the team. The patient's role at each stage is narrow and practical. - **Week 0.** Provide an accurate medication history including dose and duration, prior treatment documentation where available, and insurance card. The medication-trial log is the single most useful document a patient can prepare before the evaluation. - **Weeks 1-4.** Show up rested. Report any new medications, supplements, or significant life changes — they may affect tolerability or response. Complete the weekly PHQ-9 honestly; an inflated or deflated score is not useful clinically or administratively. - **Weeks 4-6.** Continue weekly PHQ-9 documentation. Flag tolerability concerns early rather than waiting for the mid-course assessment. - **Weeks 7-9.** Discuss maintenance preferences with the treating psychiatrist. Patients with strong views about scheduled versus symptom-triggered models should bring those views into the conversation; the decision is individualized and explicitly collaborative. ## For referring providers The clinic accepts external referrals for TMS consultation, and the workflow is designed to fit cleanly into a referring provider's existing care plan. - **Medication management can remain with the referring psychiatrist.** The clinic's treating psychiatrist performs the TMS evaluation, signs the medical-necessity letter for prior authorization, and oversees the acute course; ongoing pharmacotherapy can stay with the referring prescriber if both clinicians and the patient prefer that arrangement. - **The medical-necessity letter is signed by the treating psychiatrist at the clinic.** Referring providers are not asked to complete prior-authorization paperwork; they are asked to share existing treatment summaries and the medication-trial history where available. - **Treatment summaries are sent at the end of the acute course** (with patient consent), and again at the end of the taper if a maintenance pathway is selected. Interim updates are available on request — the standard cadence is a brief update at the mid-course assessment if the referring provider wants one. - **Re-induction after relapse** is available without a new referral if the patient was previously seen in the clinic. Referring providers who want to confirm the clinic's approach before sending a patient can review the [TMS therapy](/services/tms-therapy/) page; specific questions about candidacy or workflow can be directed to the clinical team by phone. ## Key takeaways - The first 90 days at Healing TMS Clinic typically run nine to twelve weeks across three phases: **Week 0** (inquiry, evaluation, insurance), **Weeks 1-6** (acute treatment), and **Weeks 7-9** (taper and the maintenance decision). - The first session is the longest — **60 to 90 minutes** — because it includes motor-threshold mapping, a one-time calibration step. Subsequent sessions run approximately 10 to 20 minutes (iTBS) or 40 minutes (10 Hz rTMS). - Acute-phase sessions run **five days per week** for approximately six weeks; PHQ-9 is administered weekly to document trajectory. - The taper steps down over two to three weeks (a common pattern is three sessions, then two, then one) before the maintenance decision. - The same treating psychiatrist and the same insurance coordinator stay with the patient through all 90 days; coordination with the patient's other providers continues throughout. - External referrals are welcomed; medication management can remain with the referring psychiatrist, and a treatment summary is sent at the end of the acute course with the patient's consent. Patients across Anaheim, Orange County, and the broader 30-mile radius considering TMS can begin with the [TMS questionnaire](/tms-questionnaire) or a phone call; the [insurance verification](/insurance/verify/) team confirms benefits and prior-authorization details in parallel with the clinical evaluation, and the [TMS therapy](/services/tms-therapy/) page documents the clinic's approach to candidacy, protocol selection, and the acute course described above. ## Sources / Further reading [^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 Stimul*. 2016;9(3):336–346. [^lerner-2019]: Lerner AJ, Wassermann EM, Tamir DI. Seizures from transcranial magnetic stimulation 2012–2016: results of a survey of active laboratories and clinics. *Clin Neurophysiol*. 2019;130(8):1409–1416. [^rossi-2021]: Rossi S, Antal A, Bestmann S, et al. Safety and recommendations for TMS use in healthy subjects and patient populations with updates on training, ethical and regulatory issues: Expert Guidelines. *Clin Neurophysiol*. 2021;132(1):269–306. [^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.