Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: Transcranial Magnetic Stimulation (TMS)

The insurer denied coverage for transcranial magnetic stimulation

The denial is overturned

This patient is a male with a diagnosis of bipolar disorder-depressed type and had multiple past medications trials with either lack of efficacy or side-effects including serotonin reuptake inhibitors (i.e., fluoxetine, paroxetine, sertraline, and citalopram), serotonin norepinephrine reuptake inhibitor (i.e., duloxetine), dopamine norepinephrine inhibitor (i.e., bupropion), antidepressant with unique mechanism of increasing serotonin and norepinephrine (i.e., mirtazapine and trazodone), and tricyclic antidepressants (i.e., nortriptyline and amitriptyline). The patient has tried mood stabilizers (i.e., lithium, lurasidone, vraylar, quetiapine, and lamotrigine). The patient had a history of past suicidal ideation, depressed mood, hopelessness, and past hypomanic symptoms including restlessness, hypersexuality, and sleeping problems. It was reported that the patient had two past hospitalizations for serotonin syndrome and bipolar depression. The request was for transcranial magnetic stimulation therapy.

According to the Gold et al. (2019), the literature states that TMS is a promising approach for treatment of depression in bipolar disorder who failed to respond to pharmacological or psychosocial treatment.  Also, according to Nahas et al. (2003), the literature states that daily left prefrontal TMS appears safe in bipolar depression subjects and the risks of inducing mania is small. 

In this case, this patient had multiple trials of antidepressants and mood stabilizer medications including serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, dopamine norepinephrine inhibitor, antidepressant with unique mechanism of increasing serotonin and norepinephrine, and tricyclic antidepressants. The patient also tried mood stabilizers. The patient either had reports of lack of sustained efficacy or medication side-effects that made the medication intolerable. With this patient's history of past suicidal ideation, depressed mood, hopelessness, and past hypomanic symptoms including restlessness, hypersexuality, and sleeping problems, TMS appeared to be an appropriate treatment option and medically necessary treatment. It was reported that the patient had 2 past hospitalizations for serotonin syndrome and bipolar depression so he was considered a high risk patient if not treated for his depression. 

The Food and Drug Administration (FDA) granted breakthrough device designation for TMS for the treatment of bipolar disorder and with some other literature supporting its efficacy and safety for treatment of depression in bipolar disorder. This breakthrough device designation is intended to help patients and providers receive more timely access to breakthrough technology that has potential to provide more effective treatment. This is considered medically appropriate for this patient's case. 

Based on the review above, TMS is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for transcranial magnetic stimulation (TMS) with diagnosis code F33.2 should be reversed. The medical necessity is substantiated