Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder.
Treatment: Transcranial Magnetic Stimulation (TMS).
The insurer denied the Transcranial Magnetic Stimulation (TMS). 
The denial is overturned. 

The patient is a female with a diagnosis 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 two antidepressants with disparate mechanism of action and at least three or more trials with antidepressant medications (fluoxetine, sertraline and bupropion), as well as augmentation with lamotrigine and topiramate. The patient has also received lorazepam and trazodone to address symptoms of anxiety and insomnia. Due to adverse effects or lack of efficacy, the patient has continued to experience severe symptoms of depression and functional impairments that impact quality of life and day-to-day responsibilities. Additionally, the patient has had treatment with cognitive behavioral therapy targeting posttraumatic stress disorder and major depressive disorder.

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 general medical issues.

Mental status examination reveals depressed mood, sad affect with anxiety, and anhedonia. She has loss of interest and low energy with fatigue and other neuro-vegetative disturbances related to depression. The patient's Patient Health Questionnaire Nine (PHQ-9) score was 21 at the time of initial evaluation for transcranial magnetic stimulation (TMS) therapy. She is noted to be motivated for treatment.

The patient's clinician recommended treatment with a course of deep and repetitive transcranial magnetic stimulation (rTMS) therapy with the usual treatment with up to 36 treatment episodes. The recommendation is in the context of an episode of depression that is treatment-resistant/refractory.

Coverage of the transcranial magnetic stimulation (TMS) therapy is requested. The health plan has denied authorization for coverage of repetitive transcranial stimulation (rTMS) on the basis of coverage exclusion and indicates that the requested treatment is not a covered benefit with reference to the plan's Behavioral Health Policy concerning transcranial magnetic stimulation (TMS) therapy. Specifically, the plan requires at least four treatment failures and a diagnosis of major depressive disorder and treatment with an evidence-based psychotherapy in order for transcranial magnetic stimulation (TMS) to be approved for coverage.

Yes, the requested health service, transcranial magnetic stimulation mental health services for treatment of refractory, major depressive disorder, is medically necessary for this patient.

Per the health plan documents and submitted information, transcranial magnetic stimulation mental health services is clinically appropriate and considered medically necessary as an adjunct and augmentation of the patient's antidepressant regimen in order to achieve a remission of symptoms related to severe major depressive disorder in the context of treatment refractory depression and failed trials with at least three antidepressants with disparate mechanisms of action and with several appropriate augmentation strategies. Moreover, the coverage of transcranial magnetic stimulation mental health services for a patient who meets criteria for treatment refractory depression and who is a reasonable candidate for the requested benefit of transcranial magnetic stimulation (TMS) should be approved in this case scenario; the requested transcranial magnetic stimulation (TMS) therapy proposed is in the best interest of the patient, and reflects sound medical judgment with respect to the use of the requested treatment. Transcranial magnetic stimulation (TMS) therapy for the treatment of major depressive disorder is a well-established treatment that is proposed for this patient in keeping with prevailing standards of medical practice for the condition under treatment in this case; and, the requested services/treatment in this case is clinically appropriate, and backed by credible scientific evidence known to benefit patients with the conditions diagnosed in this case-severe depressive disorder associated with severe symptoms and impairments of functioning.

This answer is consistent with the scientific literature, referenced below. This answer is also consistent with New York State instruction for medical necessity reviews.

The requested service of transcranial magnetic stimulation (TMS) therapy is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-base treatment; and, the requested services/treatment being provided in this case are clinically appropriate, and are backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case.