Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Major depressive disorder.
Treatment:  Transcranial Magnetic Stimulation (TMS).

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

This is a male patient with a history of major depression, anxiety, post-traumatic stress disorder, vitamin D deficiency, and gastroesophageal reflux disease (GERD) with complaints of depression and anxiety.  He had depressive symptoms, including depressed mood, suicidal ideation, feelings of hopelessness and worthlessness, anhedonia, low energy, motivation, pleasure, and interest, negative thinking, and impairment in occupational and social functioning.  He had a diagnosis of major depressive disorder-severe-recurrent.  He also had reported diagnoses of generalized anxiety disorder and bulimia nervosa.  He had past antidepressant medication trials without reported significant efficacy.  He also had taken anti-anxiety medications.  He was in a current major depressive episode with the above mentioned depressive symptoms.  He has had a history of depression for many years.  His provider requested transcranial magnetic stimulation therapy (TMS) for the treatment of depression.

The 2011 Federally Funded Effective Health Care Program of the Agency for Health Care Research and Quality published comparative effectiveness reviews and concluded that there was a substituted and well replicated body of evidence for randomized sham controlled clinical trials providing high strength of evidence that TMS 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 Practice Guidelines for the Treatment of Major Depressive Disorders considers TMS 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-severe-recurrent, which is an FDA-approved diagnosis for TMS treatment, and he was in a current reported major depressive episode and had reports of depressive symptoms including depressed mood, suicidal ideation, feelings of hopelessness and worthlessness, anhedonia, low energy, motivation, pleasure, and interest, negative thinking, and impairment in occupational and social functioning.

The patient tried and failed several FDA-approved antidepressant medications in different classes.  The standard recommendation for TMS treatment is for patients who failed or who did not have satisfactory improvement from 1 past anti-depressant medication at or above minimal effective dose and duration in the current episode.  The patient was considered a candidate for TMS treatment, as he had taken multiple different antidepressant medications without efficacy and was not currently responding to an adequate dose of the antidepressant, Desvenlafaxine.  This patient appeared to have treatment resistant major depressive disorder and had multiple past trials of anti-depressant medications, psychotherapy, and meditation.  He was reportedly a candidate for TMS, as this is considered standard for the treatment of major depressive disorder.  

It did not appear that the health care plan acted reasonably or in the best interests of the individual.

Based on the above, the medical necessity for TMS is substantiated.  The insurer's denial is overturned.