Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees major depressive disorder.  Findings:  Two physician reviewers found that the patient has a long-standing history of depression. She has been diagnosed with major depressive disorder, severe, recurrent. A letter from the patients provider indicates that her depression has escalated over the past year and required a partial hospitalization program (PHP) program. She was also hospitalized the following year for severe depressive symptoms and suicidal ideation. The patient is currently unable to work due to her depressive symptoms. Her symptoms include: lack of joy in her life; feeling like a failure; feeling overwhelmed by depression; feeling like a burden; suicidal ideation; crying; difficulty focusing; sleep disturbance; low energy; and lack of motivation. The patient has been treated with multiple pharmacological treatments, all of which have resulted in little or no improvement in her symptoms. Specifically, she has received Lexapro 20 mg + Seroquel 300 mg for over 12 weeks, Paxil 40 mg for over 10 weeks, Wellbutrin 300 mg for 4 weeks, Remeron 30 mg,  duloxetine 90 mg for over 12 weeks and fluoxetine 40 mg + Abilify 5 mg for over 12 weeks.  The provider indicated that electroconvulsive therapy was considered, but that TMS has been recommended due to a lesser chance for side effects. The patient has requested authorization for TMS therapy. The Health Plan has denied this request, indicating that the requested TMS therapy is investigational for treatment of the patients depression.The FDA has approved TMS as a specific treatment for severe depression and has set forth guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) approved Category I CPT codes for TMS as of January 2011. The patient states in her letter that ECT was seriously considered and rejected because of its potential side effects. Several articles, including a paper by Grunhaus and colleagues, show that TMS compares favorably with ECT. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups.  This patient has been treated with multiple trials of different medication regimens and continues to be symptomatic. The provider recommended treatment with TMS, due to potential side effects with ECT. The cited articles show that TMS has a favorable side effect profile and benefit ratio when compared to ECT. Consistent with this clinical support, the requested TMS therapy is likely to be beneficial than other available standard therapies for treatment of this patients medical condition.