Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Mental Health/Depression/MDD (Major Depressive Disorder).
Treatment:  Mental Health/Outpatient/Transcranial Magnetic Stimulation (TMS) Therapy.

The health plan denied the Mental Health/Outpatient/Transcranial Magnetic Stimulation (TMS) Therapy.  The health plan's determination is overturned.

The patient is an adult male diagnosed with major depressive disorder, recurrent and severe without psychotic features and treatment refractory/resistant depression. The patient has longstanding depression with depressed mood, anhedonia, hopelessness, worthlessness, and intermittent suicidal ideation, as well as vegetative symptoms of depression and low energy and concentration difficulties. He has been hospitalized in the past to address the depressive disorder.

The patient has a documented history of multiple medication treatments for depression including treatment with more than two disparate classes of medication and at least four or more trials with antidepressant medications (Trintellix, Remeron). He has had augmentation with Seroquel and Adderall, as well as current treatment with Luvox, propranolol and Trazodone. Due to adverse effects and/or lack of efficacy, the patient has continued to experience severe symptoms of depression. Additionally, the patient has received 8 months of cognitive behavioral therapy (CBT) which was ineffective. PHQ (Patient Health Questionnaire)-9 Depressive Severity Scale score is 17, General Anxiety Disorder (GAD) 7 Scale score is 17, and Quick Inventory of Depressive Symptomatology (QIDS) scale score is 17, reflecting a moderately severe or severe depression with severe anxiety.

The patient has comorbid obsessive-compulsive disorder (OCD) and generalized anxiety disorder, and he is diagnosed with co-occurring alcohol use disorder in partial remission with 10 weeks of sobriety.  

The patient's clinician has recommended treatment with a repeat course of repetitive transcranial magnetic stimulation (rTMS) therapy that would generally include up to 36 treatment episodes/TMS sessions. The recommendation is in the context of the ongoing episode of depression that is treatment-resistant/refractory with a history of intolerance or lack of response to antidepressant medications with augmentation combined with psychotherapy-CBT.

The health plan's determination regarding the proposed health service or treatment with TMS targeting depressive disorder is overturned, in whole. 

Yes, the proposed health service or treatment TMS Therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease, treatment resistant major depressive disorder.

Rationale: The requested benefit of Repetitive Transcranial Magnetic Stimulation (rTMS) is reasonable, clinically appropriate, and in the patient's best interest. The requested TMS service is backed by credible scientific study and is consistent with prevailing standards of medical practice for the condition under treatment in this case, recurrent major depressive disorder and treatment refractory/resistant depressive disorder.

The proposed treatment can reasonably be expected to provide the patient with greater net health benefit than any other standard therapy in this case scenario. Repetitive TMS therapy as a primary or adjunctive therapy for treatment of depression has generally been evaluated in patients who have had treatment resistant or treatment refractory depression, as defined by one or more, treatment failures with or without augmentation. TMS therapy for depression is established as a safe treatment by the Food and Drug Administration (FDA), and the data as reflected in peer reviewed medical literature supports this assertion. Specifically, when treatments with antidepressant medication with or without augmentation, or electroconvulsive therapy, and/or psychotherapy (especially cognitive behavioral therapy) have failed, then TMS is clinically appropriate. This assertion is also noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below.