Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Surgical Services (All). 
The insurer denied Transcranial Magnetic Stimulation (TMS). 
The denial is overturned. 

The patient is a male with a history of major depressive disorder, recurrent and severe without psychotic features and treatment resistant/refractory 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 four or more trials with antidepressant medications, selective serotonin reuptake inhibitor (SSRI)s, trazodone, and Wellbutrin, as well as combination treatment and augmentation with clonazepam. Additionally, the patient has been treated with psychotherapy including cognitive behavioral therapy (CBT), 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 is also diagnosed with a co-morbid generalized anxiety disorder, panic disorder and agoraphobia. The depression and anxiety is longstanding with early onset and worsening during late adolescence. The patient had psychiatric hospitalization with a suicide attempts or suicidal behavior, and a brief psychiatric hospitalization while in the fourth grade. There is no report of other co-morbid psychiatric disorders or co-occurring substance use disorders in this case though the patient has used marijuana and tobacco. The patient has no significant or acute general medical issues.
The Patient Health Questionnaire (PHQ-9) score was scored at 19 and the Generalized Anxiety Disorder (GAD) 7 was scored at 18 at the time of evaluation for transcranial magnetic stimulation (TMS) therapy reflecting severe symptoms of depression and anxiety. The patient's clinician recommended treatment with a course of repetitive transcranial magnetic stimulation (rTMS).
At issue is the medical necessity of Transcranial Magnetic Stimulation (TMS).

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

The requested health service/treatment of Transcranial Magnetic Stimulation (TMS) is medically necessary for this patient.
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 United States Food and Drug Administration (FDA) and the data as reflected in the peer reviewed medical literature which 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 may be appropriate. This assertion is also noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder.
Therefore, the requested health service/treatment of Transcranial Magnetic Stimulation (TMS) is medically necessary.