Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obsessive-compulsive disorder, generalized anxiety disorder, and major depressive disorder.
Treatment: Transcranial Magnetic Stimulation (TMS).
The insurer denied: Transcranial Magnetic Stimulation (TMS).
The denial is overturned.

The patient is an adult female who was reported to have been diagnosed with major depressive disorder, generalized anxiety disorder and obsessive-compulsive disorder. She was reported to have treatment resistant depression as she had failed to respond to trials of multiple antidepressant medications and augmenting agents to antidepressant medications for treatment of major depressive disorder. The patient's provider is requesting transcranial magnetic stimulation (TMS) therapy for treatment of symptoms related to major depressive disorder. The primary diagnoses indicated and the request for TMS (transcranial magnetic stimulation) treatment was major depressive disorder, recurrent, severe without psychotic features (F33.2). The requested TMS (transcranial magnetic stimulation) treatment was noted to have been previously denied coverage by the health plan, as the treatment for any other indication including, but not limited to, obsessive-compulsive disorder (OCD) and anxiety, was considered experimental/investigational or unproven. Clinical documentation provided indicates that the patient had previously failed trials of antidepressant medications including fluvoxamine, sertraline and fluoxetine at adequate dosages and duration due to lack of efficacy. The patient was also noted to have failed a trial of aripiprazole for augmentation of antidepressant treatment due to adverse effects. She was also noted to have been treated with L-methylfolate (Deplin) which was reported to have been ineffective. The patient was reported to have had extensive weekly psychotherapy interventions including cognitive behavioral therapy, which was noted to have been ineffective. The patient was reported to have a score of 18 on the Patient Health Questionnaire (PHQ-9) administered recently, indicating moderately severe depressive symptoms. The patient was not reported to have any history of suicide attempts. The patient was not reported to have any history of seizures or traumatic brain injury. She was not reported to have any contraindications for use of transcranial magnetic stimulation (TMS) treatment. The patient was noted to have been seen for a comprehensive psychiatric evaluation last month. She was noted to have a medical history significant for endometriosis. The patient was reported to have had behavioral health symptoms for the past 18 years. She was reported to have significant obsessive thoughts and compulsive behaviors. Most recently, the patient was noted to have been prescribed psychotropic medications including fluvoxamine and L-methylfolate. She was noted to have scored 12 on the PHQ (patient health questionnaire)-9, indicating moderate depressive symptoms and 16 on the Quick Inventory of Depressive Symptomatology (QIDS) indicating severe depressive symptoms.

The health plan should cover the requested transcranial magnetic stimulation for treatment of major depressive disorder. 

There is significant evidence in current peer reviewed, evidence-based medical literature to indicate the safety and efficacy of transcranial magnetic stimulation (TMS) treatment for treatment resistant depression and obsessive-compulsive disorder. Transcranial magnetic stimulation (TMS) has been shown to be effective for treatment resistant major depressive disorder. There is significant evidence in current peer reviewed, evidence-based medical literature indicating the clinical benefit of transcranial magnetic stimulation (TMS) therapy for treatment resistant depression (1-12). More recently, TMS (transcranial magnetic stimulation) treatment has been shown to be safe and effective for treatment of obsessive-compulsive disorder (13-16). Therefore, the health plan should cover the requested health service.