Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obsessive Compulsive Disorder.
Treatment: Repetitive Transcranial Magnetic Stimulation.
The insurer denied the Repetitive Transcranial Magnetic Stimulation.
The determination is overturned.

The patient was diagnosed with obsessive compulsive disorder (OCD) associated with anxiety and depression, and with severe symptoms and impaired functioning. The patient scored 27/40 on the Yale-Brown Obsessive Compulsive Scale (YBOCS) reflecting moderately severe symptoms of OCD.
The patient has a history of co-morbid major depressive disorder, generalized or unspecified anxiety disorder, attention deficit hyperactivity disorder (ADHD)with associated treatments, and co-occurring cannabis use disorder. There is no other substance use disorder in this case and no acute general medical issues.
The patient has received medication trials with selective serotonin reuptake inhibitors (SSRIs) (Prozac and Luvox), Cymbalta and stimulants with the latter targeting ADHD. She has also received treatment with cognitive-behavioral therapy (CBT) without substantial improvement in symptoms of OCD or functioning. She has attended mentalizing group sessions.
The patient's clinician has recommended treatment with repetitive transcranial magnetic stimulation (rTMS) therapy with a clinically appropriate number of sessions and with a protocol to address the patient's OCD.
The case summary and case records provided by the clinician, health plan documents, correspondence from the health plan and patient's clinician and the patient were reviewed, as well as appeal documents, and the plan's Behavioral Health Policy pertaining to TMS procedures and the Summary Plan Description were reviewed.
The health plan has denied the TMS. At issue is the medical necessity of Repetitive Transcranial Magnetic Stimulation (rTMS).
The requested health service/treatment of TMS is medically necessary for this patient.
Repetitive TMS therapy as a primary or adjunctive therapy for treatment of major depression and for OCD has generally been evaluated in patients who have treatment refractory or pharmaco-resistant symptoms, as defined by one or more, antidepressant medication treatment failures with or without augmentation, and with or without psychotherapy, especially cognitive behavioral therapy, as in this case.
Transcranial magnetic stimulation therapy, as applied in OCD, is considered to be a safe treatment by the FDA(Food and Drug Administration). The data as reflected in peer reviewed medical literature supports this assertion.
Specifically, when treatments with antidepressant medication with or without augmentation, and/or psychotherapy (especially cognitive behavioral therapy) have failed, then TMS is an appropriate treatment for OCD with the application of protocols as outlined in the scientific literature. The TMS protocol for treatment of OCD is different from that for depressive disorder, as the treating clinician asserts, and this assertion is supported by the scientific literature.The requested service, repetitive transcranial magnetic stimulation (rTMS), is reasonable, clinically appropriate, medically necessary and consistent with prevailing standards of care based on the scientific literature and published guidelines, referenced below.