Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: Transcranial Magnetic Stimulation (TMS.)

The insurer denied coverage for Transcranial Magnetic Stimulation (TMS.)

The denial is overturned.

This patient reportedly had a diagnosis of Major Depressive Disorder (MDD) -
treatment resistant, and Generalized Anxiety Disorder and had a past diagnosis of Bipolar Disorder. The patient, reportedly, still had depressive symptoms including depressed mood, decreased interest, pleasure, and energy, sleeping and appetite problems, and hopelessness. She also had anxiety symptoms including worrying. The patient reportedly tried many different antidepressant medications including Selective serotonin reuptake inhibitors (SSRIs) as she took Prozac, Lexapro, Zoloft; Serotonin-norepinephrine reuptake inhibitor (SNRIs) in Effexor and Cymbalta, and a dopamine norepinephrine reuptake inhibitor in Bupropion, and Sinequan, another antidepressant. The patient also reportedly tried Zyprexa and Seroquel. It was noted the patient also took Xanax and Methylphenidate. It was reported that these medications were ineffective and that she had side effects of seizures when taking Effexor. The patient reportedly also had past concussions. The patient had 3 past mental health providers prior to this provider who requested transcranial magnetic stimulation therapy (TMS).
The insurer denied coverage for transcranial magnetic stimulation therapy (TMS) stating that it was not medically necessary because it was reported that the patient had a diagnosis of Bipolar Disorder and not did not have a primary diagnosis of treatment resistant major depressive disorder.

The medical records provided enough specific evidence to support that she required transcranial magnetic stimulation therapy (TMS). According to the medical records provided, the current mental health provider stated that the patient did not have a diagnosis currently of bipolar disorder, had no bipolar symptoms, never had a full blown manic episode or hospitalizations due to bipolar disorder, and stated that the patient had a primary diagnosis of Major Depressive Disorder-treatment resistant and also had a diagnosis of Generalized Anxiety Disorder. 

The patient had adequate trials of antidepressant medications and transcranial magnetic stimulation therapy (TMS) is Food and Drug Administration (FDA) approved for the treatment of major depressive disorder. The patient's current mental health provider stated that the patient's diagnosis was Major Depressive Disorder and not bipolar disorder. 

According to O'Reardon, "Efficacy and Safety of Transcranial Magnetic Stimulation Therapy in Acute Treatment of Major Depressive Disorders" it is worth noting that patients had failed to benefit from prior antidepressant drug medications and demonstrated a level of treatment resistance similar to patients treated in studies of Electroconvulsive therapy (ECT). Transcranial magnetic stimulation therapy also showed clinical efficacy and safety for the treatment of major depressive disorders. The average patient had 4 medication attempts. 

This patent was considered a candidate for transcranial magnetic stimulation therapy as the patient did not have prolonged efficacy or had reports of side effects from multiple past antidepressant medications including SSRI's as the patient took Prozac, Lexapro, Zoloft, SNRI's in Effexor and Cymbalta, and a dopamine norepinephrine reuptake inhibitor in Bupropion, and Sinequan, another antidepressant.  Thus, the patient was considered a candidate for transcranial magnetic stimulation therapy (TMS).  

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Transcranial Magnetic Stimulation (TMS) is substantiated. The insurer's denial is reversed.