Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder-severe-recurrent
Treatment: Transcranial magnetic stimulation (TMS)
The insurer denied coverage for transcranial magnetic stimulation (TMS).
The denial is overturned. 

This is a female patient with a diagnosis of major depressive disorder-severe-recurrent, who reportedly had depressive symptoms including depressed mood, anhedonia, lack of energy, poor concentration, sleeping problems, feelings of hopelessness and worthlessness. She was reportedly in another major depressive episode. She had past successful transcranial magnetic stimulation (TMS) therapy but her depression reemerged. It was reported that she had multiple failed trials of antidepressant medications without reported efficacy or with adverse effects. The request was for repeat TMS therapy 36 sessions, which the insurer denied.

In this case, TMS therapy for 36 sessions to treat depression was not considered maintenance treatment but rather, treatment for another major depressive episode. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V) reports that for Major Depressive Disorder if there is another major depressive episode after remission it is considered another episode which was the case with this patient as she had reports of past TMS therapy treatment with efficacy and now has reported depressive symptoms and another major depressive episode. 

The Food and Drug Administration (FDA) approved Neurostar Transcranial Magnetic Stimulation Therapy for the treatment of depression.  TMS therapy was cleared by the FDA and indicated for the treatment of major depressive disorder in patients who failed or who did not have satisfactory improvement from 1 past antidepressant medication at or above minimal effective dose and duration in the current episode.  Neurostar TMS Therapy System was the largest multisite (23 centers) randomized sham controlled trial ever conducted with TMS therapy. This was the principal study for the FDA's approval of TMS therapy for major depressive disorders.  In addition, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Major Depressive Disorders considers TMS therapy as an appropriate acute phase option for patients who do not respond adequately to pharmacotherapy or psychotherapy and were considered treatment resistant.  

In this case this patient had a documented diagnosis of major depressive disorder-severe, which is an FDA approved diagnosis for TMS therapy treatment, and tried and failed multiple antidepressant medications. Also, she reportedly had cognitive behavioral therapy and individual psychotherapy in the past. 

She had many past antidepressant trials without reported sustained efficacy and she had documentation that the past TMS therapy treatment was effective so this was evidence that another TMS therapy treatment was considered medically necessary for this new major depressive episode. Furthermore, she tried many antidepressant medications without sustained efficacy and TMS therapy treatment was effective in the past.

TMS as requested was medically necessary. It did not appear that the health care plan acted in the best interests of the patient then.

The carrier's denial of TMS is overturned. The medical necessity is substantiated.