Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Transcranial Magnetic Stimulation (TMS)
The insurer denied the request for TMS.
The health plan's determination is overturned. 

The patient is a male who is diagnosed with major depressive disorder, recurrent and severe without psychotic features and treatment refractory/resistant depression. The patient has longstanding depression with depressed mood, anhedonia, and hopelessness, as well as vegetative symptoms of depression and low energy and concentration difficulties. He is diagnosed with comorbid generalized anxiety disorder. There is no substance use disorder in this case.
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 trials with antidepressant medications (selective serotonin reuptake inhibitor (SSRI), serotonin norepinephrine reuptake inhibitor (SNRI) and Wellbutrin). He has had augmentation/supplementation with Lorazepam targeting anxiety, as well as current treatment with Cymbalta and Melatonin and Lorazepam. Due to lack of efficacy or adverse effects with antidepressant medications, the patient has continued to experience severe symptoms of depression. His most recent evaluation includes a Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) scale score of 18 reflecting a severe depression with associated symptoms of anxiety and the comorbid generalized anxiety disorder (GAD).
The patient's clinician has recommended treatment with repetitive transcranial magnetic stimulation (rTMS) therapy that would generally include up to 36 treatment episodes/transcranial magnetic stimulation (TMS) sessions. The recommendation is in the context of the ongoing episode of depression that is treatment-resistant/refractory with a history of intolerance or lack of response to antidepressant medications, as well as weekly psychotherapy with cognitive behavioral therapy (CBT).
Coverage of the TMS therapy is requested. The appeal indicates that the health plan criteria are met as the patient has severe and treatment resistant depression with multiple failed antidepressant trials with augmentation/supplementation-as noted in the clinical summary. The appeal indicates that the denial determination is incorrect and not proper, as the patient meets criteria for treatment resistant depression and has a primary diagnosis of major depressive disorder, and the appeal indicates that a course of TMS therapy for treatment of the depressive disorder is medically necessary and clinically appropriate in this case. The appeal asserts that the diagnosis of GAD is secondary though TMS is known to benefit GAD and that GAD is not a contraindication to treatment of depression with TMS therapy.

The proposed health service or treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The requested benefit of Repetitive Transcranial Magnetic Stimulation (rTMS) is reasonable, clinically appropriate, and in the patient's best interest. The requested TMS service is backed by credible scientific study and is consistent with prevailing standards of medical practice for the condition under treatment in this case, recurrent major depressive disorder, and treatment refractory/resistant depressive disorder. 

The health plan's determination regarding the proposed health service or treatment is overturned in whole.