Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/Other/Major Depressive Disorder.
Treatment: Mental Health: Outpatient.
The health plan denied the requested mental health outpatient treatment as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a history of major depressive disorder, recurrent and severe without psychotic features. The patient has comorbid conditions that include eating disorder not specified, generalized anxiety and borderline personality traits. 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 (SSRIs-Luvox, Zoloft and Lexapro, SNRI-Cymbalta, Trazodone, and Wellbutrin), as well as use of other medications including Topamax, Vyvanse and Prazosin. Additionally, the patient has been treated with Ketamine infusions, and with psychotherapy including cognitive behavioral therapy and dialectical behavioral therapy (CBT & DBT), as well as counseling and supportive psychotherapy.
Due to adverse effects or lack of efficacy, the patient has continued to experience severe symptoms of depression and functional impairments that impact quality of life and day-to-day responsibilities.
The patient has reportedly not had psychiatric hospitalization or suicide attempts. She has had partial hospital treatment with three treatment episodes and ongoing DBT group sessions to address borderline personality traits. There is no report of other co-morbid psychiatric disorders or co-occurring substance use disorders in this case. The patient has no significant general medical issues except for gastroesophageal reflux disease (GERD) and history of migraine headaches. Issue under review:  Transcranial Magnetic Stimulation (TMS) Therapy for Major Depressive Disorder and Treatment Refractory Depression.

The health plan's determination of medical necessity is overturned, in whole.

The requested benefit of Repetitive Transcranial Magnetic Stimulation (rTMS) is reasonable, clinically appropriate, medically necessary, and in the patient's best interest. 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 depressive disorder.
The proposed treatment can reasonably be expected to provide the patient with greater net health benefit than any other available 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, electroconvulsive therapy, and/or psychotherapy (especially cognitive behavioral therapy) have failed, then TMS is an appropriate treatment option. This assertion is also noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below.