Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: Transcranial Magnetic Stimulation (TMS) Treatments (initial, including cortical mapping, motor threshold determination, delivery) 
The insurer denied: Transcranial Magnetic Stimulation (TMS) Treatments (initial, including cortical mapping, motor threshold determination, delivery) 

The denial is: Overturned.

The patient is a male diagnosed with major depressive disorder, recurrent and severe without psychotic features and treatment refractory/resistant depression. 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 three or more trials with antidepressant medications (selective serotonin reuptake inhibitor [SSRIs] and Wellbutrin). He has had augmentation with Abilify and lithium, as well as ongoing treatment with Vyvanse for attention deficit hyperactivity disorder (ADHD). Due to adverse effects and lack of efficacy, the patient continued to experience severe symptoms of depression which did respond robustly to a course of transcranial magnetic stimulation (TMS) therapy. Subsequently, the patient experienced a return of depressive symptoms following a life-threatening illness with a bowel perforation complicated by sepsis requiring intensive medical treatment. The patient's clinician has recommended treatment with a repeat course of repetitive transcranial magnetic stimulation (rTMS) therapy sessions. The recommendation is in the context of the ongoing episode of depression that is treatment-resistant/refractory with a history of intolerance to antidepressant medications. 
The subject under review is the medical necessity for Transcranial Magnetic Stimulation (TMS) Therapy for recurrent and severe Major Depressive Disorder without psychotic features and treatment refractory/resistant depression.

The requested health service/treatment of TMS Treatments (initial, including cortical mapping, motor threshold determination, delivery) is medically necessary for this patient.
The requested benefit of Repetitive Transcranial Magnetic Stimulation (rTMS) is reasonable, clinically appropriate, and medically necessary in this case. The requested TMS service is backed by credible scientific study and is consistent with prevailing standards of medical practice for the condition under treatment in this case, recurrent major depressive disorder and treatment refractory/resistant depressive disorder.
The proposed treatment can reasonably be expected to provide the patient with greater net health benefit than any other standard therapy in this case scenario. Repetitive TMS therapy as a primary or adjunctive therapy for treatment of depression has generally been evaluated in patients who have had treatment resistant or treatment refractory depression, as defined by one or more, treatment failures with or without augmentation. TMS therapy for depression is established as a safe treatment by the Food and Drug Administration (FDA), and the data as reflected in peer reviewed medical literature supports this assertion. Specifically, when treatments with antidepressant medication with or without augmentation, or electroconvulsive therapy, and/or psychotherapy (especially cognitive behavioral therapy) have failed, then TMS is clinically appropriate. This assertion is also noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below.
The patient in this case has demonstrated that his depressive disorder is treatment refractory with multiple failed trials of antidepressant medications of disparate mechanisms of action, as noted in the clinical summary. Thus, the proposed treatment of recurrent and severe major depressive disorder using rTMS therapy is considered medically necessary in this case.