Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Transcranial Magnetic Stimulation (TMS) Therapy Session(s)
The health plan denied the requested Transcranial Magnetic Stimulation (TMS) Therapy Session(s) as not medically necessary.
The health plan's determination is overturned.

Clinical Summary: The patient is an adult female with a longstanding history of major depressive disorder, recurrent and severe without psychotic features. 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 six-week or longer trials with antidepressant medications (Wellbutrin, Lexapro, Luvox, Effexor). Additionally, the patient has received augmentation with second generation antipsychotic medications (Vraylar and Seroquel) and Lamotrigine without a sustained clinical response or remission and/or with adverse effect. She has been treated with an evidence-based psychotherapy. She has not received electroconvulsive therapy (ECT) or vagus nerve stimulation (VNS) therapy. At the time of evaluation for transcranial magnetic stimulation (TMS) therapy, the patient health questionnaire (PHQ-9) score was 25, in the severe range for symptoms of depression associated with severe impairment of functioning.

The patient has reportedly not had psychiatric hospitalization or suicide attempts or suicidal behavior. There is no report of other co-morbid psychiatric disorders or co-occurring substance use disorders in this case. The patient has no significant or acute general medical issues.

Mental status examination reveals depressed mood, sad affect with anxiety, and anhedonia together with hopelessness. She has loss of interest and low energy and other neuro-vegetative disturbances related to depression. Again, PHQ-9 score was at 25 at the time of evaluation for TMS therapy.

The health plan's determination of medical necessity is overturned, in whole.

The requested health service/treatment of Transcranial Magnetic Stimulation (TMS) is medically necessary for this patient.

The services proposed are in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-based augmentation treatment for depressive disorder with TMS therapy; and the requested service/treatment in this case is clinically appropriate, and is backed by credible scientific evidence known to benefit patients with the condition and clinical features in this case scenario.

In this case, at least four alternative therapeutic trials with augmentation together with other therapeutic measures have been provided, and the proposed treatment with TMS therapy is considered clinically appropriate and medically necessary. Additionally, the use of TMS therapy is reasonable, and in the best interest of the patient. The decision to proceed with TMS therapy reflects sound medical judgment based upon the current scientific literature and American Psychiatric Association practice guidelines concerning the assessment and treatment of major depressive disorder. The patient in this case has demonstrated that her depressive disorder is treatment refractory or resistant, and the proposed treatment of recurrent major depressive disorder using TMS therapy with a clinically appropriate number of sessions is warranted in this case scenario, and is consistent with prevailing standards of medical practice.