Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Major Depressive Disorder.
Treatment:  Transcranial Magnetic Stimulation (TMS) 36 units.

The insurer denied coverage for Transcranial Magnetic Stimulation (TMS) 36 units.  The denial is overturned.

This minor patient had severe depressive symptoms including depressed mood, feelings of hopelessness, passive suicidal ideation, poor appetite, sleeping problems, feeling bad about self, psychomotor agitation, and feeling like a failure. The patient reportedly had a Patient Health Questionnaire (PHQ)-9 score of 19, which was considered severe. The patient reportedly had diagnoses of Major Depressive Disorder - severe, Generalized Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD) - combined presentation, and Tourette's Disorder. The patient has reportedly had tics since ages 3-4 and then depression and anxiety shortly after. The patient reportedly had 2 past psychiatric hospitalizations for depression, suicidal thoughts, and rage. The patient has reportedly tried multiple antidepressant medications with inadequate efficacy including Lexapro 20 milligrams (mg), Zoloft 150 mg, Cymbalta 60 mg, Wellbutrin 300 mg, and had side effects to Prozac. The patient also tried Abilify up to 6 mg as an augmentation to the antidepressant and Risperidone up to 6 mg, as well as Thorazine. The patient reportedly also had past transcranial magnetic stimulation therapy (TMS) 3 years ago for 7 weeks and had reported efficacy with depression and also a drastic improvement in tics. The patient also took ADHD medication including Adderall, Vyvanse, Focalin, Strattera, and Intuniv. The patient's current medications include Lexapro 15 mg per day, Abilify 2 mg per day, and Intuniv 2 mg per day. The request by the patient's provider was for transcranial magnetic stimulation therapy (TMS) again to target severe depression.
  
This reviewer disagrees with the decision to deny coverage for transcranial magnetic stimulation therapy (TMS) to treat this patient's severe depressive symptoms as the medical records provided enough specific evidence to support that transcranial magnetic stimulation therapy (TMS) treatment was considered medically necessary treatment then. The Food and Drug Administration (FDA) approved Neurostar Transcranial Magnetic Stimulation Therapy for the treatment of depression in October 2008 in patients 18 years old and older and transcranial magnetic stimulation therapy was cleared by the FDA and indicated for the treatment of major depressive disorder in patients who failed or who did not have satisfactory improvement from 1 past antidepressant medication at or above minimal effective dose and duration in the current episode. This patient had a past trial of transcranial magnetic stimulation therapy (TMS) 3 years prior for 7 weeks with reported efficacy in treating depressive symptoms and also with significant improvement in tics. According to MacMaster et al. (2018), it states that a single center open trial suggests TMS is safe and effective in youth with treatment resistant major depression. Also, according to Croarkin et al. (2016), it states that transcranial magnetic stimulation therapy is feasible, tolerable, and effective in adolescents with treatment resistant major depressive disorder. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Transcranial Magnetic Stimulation (TMS) 36 units is substantiated.