Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder (MDD), Posttraumatic Stress Disorder (PTSD)

Treatment: 36 sessions of Transcranial Magnetic Stimulation Therapy

The insurer denied the 36 sessions of Transcranial Magnetic Stimulation Therapy.

The denial was overturned. 

This is a male patient with a history of Major Depressive Disorder (MDD), Posttraumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder, Cannabis Use Disorder, Borderline Personality Disorder and suicide attempts.  It was reported that the patient's Beck Depression Inventory Scale was 45.  The patient reportedly tried and failed antidepressants, including paroxetine and duloxetine, and trazodone.  The patient also reportedly had tried Depakote and Lyrica, as well as cognitive behavioral therapy, psychodynamic psychotherapy, and mentalization based therapy weekly to twice per week. Recommendations were made for transcranial magnetic stimulation therapy.

Transcranial magnetic stimulation therapy was approved by the FDA in 2008 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.  The study did not report that one needed to fail 4 antidepressant medications to be considered or qualified for the transcranial magnetic stimulation therapy.  

Neurostar TMS Therapy System was the largest multisite (23 centers) randomized sham controlled trial ever conducted with transcranial magnetic stimulation therapy.  This was the principal study for the FDA's approval of transcranial magnetic stimulation therapy for major depressive disorders in 2008.  Also, according to O'Reardon et al (2007), the study supported the clinical efficacy and safety for the treatment of transcranial magnetic stimulation therapy in the treatment of major depressive disorders. As per the Federally Funded Effective Health Care Program of the Agency for Health care research and Quality (2011), there was a substituted and well replicated body of evidence for randomized sham controlled clinical trials providing high strength of evidence that transcranial magnetic stimulation therapy procedures were significantly greater in decreasing depression severity and resulting in a greater response rate and remission rate when compared to sham treatment condition and peer reviewed published clinical trials.  In addition, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Major Depressive Disorders considers transcranial magnetic stimulation therapy as an appropriate acute phase option for patients who do not respond adequately to pharmacotherapy or psychotherapy and were considered treatment resistant.  

In this case, this patient had a documented diagnosis of Major Depressive Disorder which is an FDA-approved diagnosis for transcranial magnetic stimulation therapy (TMS) treatment. The patient has also tried and failed several FDA-approved antidepressant medications in different classes.
As per the medical literature, the standard recommendation for transcranial magnetic stimulation therapy (TMS) treatment is for patients who failed or who did not have satisfactory improvement from one past antidepressant medication at or above minimal effective dose and duration in the current episode. This applies to this patient's case. The patient was considered an ideal candidate for this transcranial magnetic stimulation therapy (TMS) treatment as he had taken three different antidepressant medications without efficacy. 

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

The carrier's denial of request for 36 sessions of Transcranial Magnetic Stimulation Therapy should be overturned.  The medical necessity is substantiated.