Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression
Treatment: Transcranial Magnetic Stimulation (TMS) 
The insurer denied Transcranial Magnetic Stimulation (TMS) 
The determination is upheld.

This is a male patient with a diagnosis of severe major depressive disorder without psychotic features. The patient has a history of depressive disorder with worsening and persistent symptoms of depression. He has received outpatient treatment with one antidepressant medication citalopram, as well as augmentation therapy with Seroquel and Abilify together with clonazepam and ongoing psychotherapy with cognitive behavioral therapy (CBT). The patient's history of depression includes symptoms of depressed mood, hopelessness, guilt, shame, anxiety and disturbed sleep with low motivation and impaired functioning. The patient has reported suicidal ideation without a plan or intent. An assessment with a Patient Health Questionnaire (PHQ) -9 scale scored 18 in the severe range.
The patient is diagnosed with comorbid post-traumatic stress disorder (PTSD) and the patient has recent losses including the death of his father and a friend and a break up with his fiance after three years. A recent progress note indicated that the patient's therapist left the practice and the patient was seeking another therapist/counselor. Also, the patient was started on sertraline with continued use of Seroquel and clonazepam.
There is no current substance use disorder or other comorbid psychiatric disorder in this case. There are no severe symptoms such as psychosis, mania, perceptual disturbance, or cognitive impairment. There is no report of psychiatric hospitalization or suicide attempt/behavior and the patient has not had a history of self-harm.
The health plan denied transcranial magnetic stimulation (TMS) therapy indicating that the requested treatment is not medically necessary because the patient has not had enough trials with antidepressant medications. The patient has received treatment with only one antidepressant medication with augmentation-as noted, and has not received treatment with at least one other antidepressant medication with a disparate mechanism of action as required under the plan's InterQual Criteria pertaining to TMS therapy.
The appeal argues that the patient meets the plan criteria with failed trials with the indicated medications and high risk for complications including hospitalization.
A case summary/case notes, health plan documents and peer advisor case notes, and correspondence from the health plan and treating clinician were reviewed, as well as appeal documents, and the plan's InterQual Medical Necessity Criteria pertaining to transcranial magnetic stimulation (TMS) therapy for major depressive disorder.
At issue is the medical necessity of Transcranial Magnetic Stimulation (TMS).
The requested health service/treatment of transcranial magnetic stimulation (TMS) is not medically necessary for this patient.
The patient has only one treatment failure with one antidepressant medication with augmentation as noted in the clinical summary. Published guidelines and scientific literature would support that the patient has not had enough antidepressant medication trials prior to considering the use of TMS therapy. In this case, the patient does not meet the standard of care for the use of TMS therapy, as the patient has not demonstrated that they have treatment resistant depression. Standard therapeutic options known to be effective in the treatment of major depressive disorder are available to this patient to address the persistence or recrudescence of depressive symptoms. The requested TMS therapy is not medically necessary consistent with prevailing standards of medical practice and the published societal guidelines and scientific literature, referenced below.