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 had a diagnosis of Major Depressive Disorder and had reports of depressed mood, lack of enjoyment, decreased energy and motivation, concentration problems, suicidal ideation, appetite changes, little interest, hopelessness, and he was struggling to attend work and was relying on a heavy amount of energy drinks. He tried multiple antidepressant medications including Wellbutrin, Zoloft, Celexa, Lexapro, as well as Vyvanse and Adderall, Abilify for augmentation and Lamictal. He either had lack of efficacy or side effects with those medications. He currently was taking Wellbutrin and Abilify and the request was for transcranial magnetic stimulation therapy (TMS). He also had a reported diagnosis of Generalized Anxiety Disorder.

 Neurostar TMS Therapy System was the largest multisite (23 centers) randomized sham controlled trial ever conducted with transcranial magnetic stimulation therapy. This was the principal study for the FDA's approval of transcranial magnetic stimulation therapy for major depressive disorders.  In addition, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Major Depressive Disorders considers transcranial magnetic stimulation 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 and was treatment resistant as he reportedly took 3 serotonin reuptake inhibitors including Zoloft, Celexa, and Lexapro, a serotonin norepinephrine reuptake inhibitor including Effexor, and a dopamine norepinephrine reuptake inhibitor including Wellbutrin, as well as augmenting medication Abilify, Lamotrigine, and took psychostimulants including Vyvanse and Adderall.

He reportedly had either lack of efficacy or side effects. He reportedly muscle stiffness when taking Zoloft, could not tolerate higher doses of Celexa, was sedated when taking Effexor, and had jitteriness and anxiety when taking Adderall and Vyvanse, and gained weight and had muscle stiffness when taking Abilify. He also reportedly had a trial of psychotherapy without prolonged efficacy. As a result, he met criteria for transcranial magnetic stimulation therapy (TMS) for treatment of major depressive disorder. The standard recommendation for transcranial magnetic stimulation therapy (TMS) treatment is for 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 and this patient met that criteria as he tried multiple antidepressant medications. He was considered a candidate for transcranial magnetic stimulation therapy (TMS) treatment, and it was considered medically necessary treatment then and is an FDA(U.S. Food and Drug Administration) approved treatment for his diagnosis of Major Depressive Disorder. As a result, the recommendation is to overturn the previous decision and approve coverage for transcranial magnetic stimulation therapy (TMS) treatment). 

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

The insurer's denial of coverage for transcranial magnetic stimulation (TMS) is overturned. Medical Necessity is substantiated.