Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for transcranial magnetic stimulation (TMS). The enrollee was diagnosed with severe major depressive disorder, recurrent. She received cognitive behavioral therapy once a week and reported benefit from the therapy, but her depression persisted. A patient health questionnaire (PHQ-9) was used to classify this diagnosis with the enrollee initially scoring 25. She underwent transcranial magnetic stimulation (TMS). On her last day of treatment, she scored a 5 on the PHQ-9. She has trialed Prozac 20mg with no relief from her depressive symptoms. Repetitive transcranial magnetic stimulation (TMS) is indicated for individuals with unipolar major depression who have failed at least one antidepressant medications. In many studies, individuals have failed multiple courses of pharmacotherapy and psychotherapy, as well as a trial of electroconvulsive therapy, and most have suffered prior episodes of major depression. Use of repetitive TMS for treatment resistant/refractory depression is consistent with treatment guidelines. In addition, TMS is indicated for those who responded to a prior course of TMS. Prior to repetitive TMS treatment, the individual is evaluated to confirm the primary diagnosis of treatment resistant depression and whether the intervention can be used safely. The assessment includes a psychiatric history and mental status examination, with emphasis upon depressive symptoms, length of the current depressive episode, types and number of failed treatments during the present episode, as well as the number, length, and treatment history of prior depressive episodes. In addition, a general medical history and physical examination is performed, as well as laboratory tests and neuroimaging studies that are guided by the history and examination. The medical work-up should emphasize risk factors for seizures and preexisting neurologic disease (eg, epilepsy, intracranial masses, and vascular abnormalities). The enrollees physician utilized the PHQ-9 depression scale. It identifies depression severity. After completing TMS, her score was 5; mild. She demonstrated improvement in severity of her depression symptoms, which had not been accomplished with pharmacotherapy and psychotherapy.  Repetitive TMS is contraindicated in individuals with an increased risks for seizures, implanted metallic hardware (e.g., aneurysm clips or bullet fragments), cochlear implants, implanted electrical devices (e.g., pacemakers, intracardiac lines, and medication pumps), or unstable general medical disorders. The enrollee does not have documented contraindications for TMS.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.