Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/Other/Major Depressive Disorder. 
Treatment: Radiology Services/Transcranial Magnetic Stimulation. 

The health plan denied the requested service as not medically necessary. 
The health plan's determination is overturned.

The patient is an adult male diagnosed with major depressive disorder, recurrent and severe without psychotic features and treatment refractory/resistant 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 inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitor (SNRI), Trintellix, and Wellbutrin), as well as augmentation treatment with Lithium, atypical antipsychotics, and Lamotrigine. Additionally, the patient has received combined pharmacologic treatment with psychotherapy including cognitive behavioral therapy (CBT). 
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 functioning. 
Co-morbid psychiatric disorders include a history of post-traumatic stress disorder (PTSD), and co-occurring substance use disorders includes cannabis use disorder in remission. Case records include a rule out for bipolar II disorder with a history of mood cycling or elevated mood for brief time intervals or in the context of cannabis use.
Mental status examination reveals a depressed mood, sad affect with anxiety, and anhedonia together with negative thoughts/depressive ruminations and episodes of passive suicidal thoughts. He has a loss of interest and low energy and motivation with decreased concentration and bouts of insomnia. There are trauma related symptoms including hypervigilance, nightmares, and avoidance. The Patient Health Questionnaire (PHQ-90) score was at 21, reflecting moderately severe to severe symptoms of depression. 
The patient is single and unemployed and lives with family. He has had some college. The patient has a trauma history that includes childhood emotional abuse. There are no legal issues in this case. 
The patient's clinician recommended treatment with a course of repetitive transcranial magnetic stimulation (rTMS) therapy that would generally include up to thirty-six treatment episodes/TMS sessions. The recommendation is in the context of the ongoing episode of depression that is treatment-resistant/refractory despite the most current treatment with Trintellix together with CBT. 

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

Yes, 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, 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/resistant depressive disorder.
 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/resistant depressive disorder. The submitted records indicate that the question of a bipolar mood disorder is a rule out and not diagnosed, and the cannabis use disorder is in full remission. Moreover, the scientific literature, referenced below, pertains to the use of TMS therapy for both unipolar and bipolar depression.