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

A 62-year-old female requested coverage for transcranial magnetic stimulation services from a specific date and onward.  Findings:  Two physician reviewers found that the patient is has an approximate 20-year history of mood symptomatologies which have been worsening over the past two years; her psychiatric diagnosis is major depressive disorder. The symptom complex consists of depressed mood with negative schemas, poor motivation, apathy, decreased energy, social isolation, anhedonia, impaired concentration with distractibility, and sleep problems.  The patient has been active in cognitive therapy for two years. There are no reports of treatment with electroconvulsive therapy or in a setting other than the outpatient setting. In terms of medications, the patient has reportedly trialed escitalopram, citalopram, fluoxetine, sertraline, bupropion, venlafaxine, duloxetine, nefazodone, buspirone, olanzapine, risperidone and quetiapine. Due to persistent affective symptomatologies, transcranial magnetic stimulation (TMS) therapy was recommended. Details regarding the number of and duration of the patients TMS sessions have not been provided. The body of evidence in the peer-reviewed literature provides adequate support for the efficacy of TMS therapy for the treatment of major depressive disorder. It is a well-tolerated procedure and carries less risk and fewer barriers when compared to electroconvulsive therapy (ECT). Further, and most compelling in support of its application, TMS is endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of individuals with depression. In this particular case, the patient has a history of an enduring unilateral mood disorder with a formidable affective symptom complex. She had trialed appropriate psychotropic medications, and pursued an evidence-based psychotherapy for the treatment of depression. As such, TMS was an appropriate modality for this patient as it was likely to be more efficacious than standard treatment options. However, while TMS is indicated in the treatment of the acute phase of depression, its utility in long-term and/or maintenance treatment for major depressive disorder has not yet been established by the scientific community. As a paper by George and colleagues suggests, at this time there is meager supporting evidence for maintenance TMS; the authors indicate that for patients who respond to TMS, one should attempt to maintain the remission with prophylactic oral medications. Thus, considering this case within the context of the most current practice guidelines and relevant peer-reviewed literature, TMS was likely to be more beneficial for treatment of the patients acute depression than any available standard therapy. However, any application of TMS as a maintenance therapy for major depressive disorder (i.e., in excess of 30 TMS sessions) would be unproven in this setting.  All told, up to 30 sessions of TMS therapy for treatment of the patients acute depression was/is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The application of TMS outside of these parameters is not supported by scientific findings and therefore would be investigational and unlikely to be more beneficial than standard therapy.