Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health 
Treatment: Mental Health Outpatient 
The insurer denied: TMS therapy
The denial is: Overturned in whole

The patient is a female with a history 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 more than two disparate classes of medication and at least four or more trials with antidepressant medications (selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitor [SNRI], Trintellix, Viibryd, and Wellbutrin), as well as combination treatment with an SSRI and Wellbutrin. Additionally, the patient has been treated with psychotherapy including cognitive behavioral therapy and dialectical behavioral therapy (cognitive behavioral therapy [CBT] & dialectical behavior therapy [DBT]) as well as counseling and supportive psychotherapy.

Mental status examination reveals depressed mood, sad affect with anxiety, and anhedonia together with hopelessness, helplessness and low self-worth with guilt and depressive ruminations. She has loss of interest and low energy with fatigue and other neuro-vegetative disturbances related to depression including insomnia with only five hours of sleep nightly or less. Patient Health Questionnaire (PHQ)-9 score was at 20-27 at the time of evaluation for transcranial magnetic stimulation (TMS) therapy reflecting severe symptoms of depression. She rates her anxiety and depression at an 8 of 10 severity, respectively. She is noted to be motivated for treatment for TMS therapy but has rejected electroconvulsive therapy on the basis of risk versus benefits and the potential for adverse effects that could impact her occupational and day-to-day functioning.

The health plan's determination is oveturned in whole.

Transcranial Magnetic Stimulation (TMS) Therapy for Major Depressive Disorder is medically necessary for this patient.
Repetitive TMS therapy as a primary or adjunctive therapy for treatment of major depression has generally been evaluated in patients who have treatment refractory or pharmaco-resistant depression, as defined by one or more, antidepressant medication treatment failures with or without augmentation, and with or without psychotherapy, especially cognitive behavioral therapy. Transcranial magnetic stimulation therapy, as applied in major depression, is considered to be a safe treatment by the FDA. The data as reflected in peer reviewed medical literature supports this assertion.
Specifically, when treatments with antidepressant medication with or without augmentation, electroconvulsive therapy, and/or psychotherapy (especially cognitive behavioral therapy) have failed, then TMS is an appropriate treatment for major depressive disorder. This assertion is noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below, and consistent with the scientific literature pertaining to TMS and its application to depressive disorder.
As noted in the answer to question 1, the requested service, repetitive transcranial magnetic stimulation (rTMS), is reasonable, clinically appropriate, medically necessary and consistent with prevailing standards of care based on the scientific literature and practice guidelines, referenced below. The patient in this case has demonstrated that her depressive disorder is treatment refractory with multiple failed trials of antidepressant medications of disparate mechanisms of action with augmentation, as noted in the clinical summary.
The patient has also failed to achieve a remission of symptoms with combined treatment with psychotherapy (CBT, DBT and Supportive Psychotherapy) and medication regimens, as noted in the clinical summary. ECT has been rejected on the basis of risk-benefit analysis. Thus, the proposed treatment of recurrent major depressive disorder using rTMS therapy is medically necessary in this case.