Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obsessive-compulsive disorder, generalized anxiety disorder, and major depressive disorder
Treatment: Transcranial Magnetic Stimulation (TMS)
The insurer denied: Transcranial Magnetic Stimulation (TMS)
The denial is upheld

The patient is an adult female with depression. Her provider is requesting transcranial magnetic stimulation (TMS). Recent Progress note reports that the patient has experienced symptoms of obsessive-compulsive disorder, generalized anxiety disorder, and major depressive for 18 years. Her symptoms improved for several years before becoming worse again over the past year. She describes anxiety symptoms consisting of feeling overwhelmed, jittery, and having difficulty catching her breath. She reports obsessions about having to do things in a certain order and compulsions of having to do things a certain number of times or having to move in a certain manner. She noted that her depressive symptoms had worsened as a result of her worsening anxiety symptoms. She denied homicidal ideation and hallucinations. She denied current suicidal ideation but admitted to these recently. She endorsed anhedonia, depressed mood, and low energy as associated symptoms. Her PHQ (patient health questionnaire)-9 score was 12, which is indicative of moderate depression. She was currently taking Luvox 50mg (milligrams) daily and stated that the medication was ineffective. She had previously tried Zoloft for 6 years, which was ineffective, Prozac for 2 years previously, which was ineffective, and Abilify for 6 months 10 years ago, which was ineffective and caused mood swings. The plan section notes that the patient had only been taking fluvoxamine 50mg (milligrams) daily for 4 months and that this dose is inadequate. It was recommended that the patient discuss increasing her dose with her psychiatrist. It also notes that the patient has only taken SSRIs (selective serotonin reuptake inhibitors) for anxiety and depression and that if fluvoxamine fails, she should consider a trial of clomipramine for both depression and anxiety, and that if this fails, TMS (transcranial magnetic stimulation) should be considered.
At issue is transcranial magnetic stimulation. Coverage was denied by the health plan as experimental/investigational because TMS (transcranial magnetic stimulation) was being requested for treatment of obsessive compulsive disorder and anxiety, which are not FDA (United States Food and Drug Administration)-approved indications for treatment with TMS (transcranial magnetic stimulation). It also notes that the patient has metal surgical hardware in her head, which is a contraindication to TMS (transcranial magnetic stimulation).
The denial decision was appealed by the treating provider, stating that TMS (transcranial magnetic stimulation) has been wrongfully denied because TMS (transcranial magnetic stimulation) will be used to treat the patient's diagnosis of major depressive disorder and not obsessive compulsive disorder or generalized anxiety disorder. It also states that the patient's PHQ (patient health questionnaire)-9 score was 18.

The health plan should not cover the requested transcranial magnetic stimulation.

Per the progress note, the patient's primary symptomatology is her obsessive compulsive disorder and anxiety symptoms. It is noted that her depressive symptoms are secondary to these symptoms and have occurred in response to her worsening anxiety. Transcranial magnetic stimulation is considered investigational or experimental for any other diagnosis aside from treatment-resistant depression. Review of the medical literature conforms that studies regarding the use of TMS (transcranial magnetic stimulation) for the treatment of OCD (obsessive compulsive disorder) have been provided inconsistent results with regards to effectiveness, and also that more robust studies regarding the use of TMS (transcranial magnetic stimulation) for generalized anxiety disorder are needed. As such, TMS (transcranial magnetic stimulation) is considered experimental/investigational in this case and should not be covered by the health plan.