Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Mental Health/Depression/MDD (Major Depressive Disorder).
Treatment:  Mental Health/Outpatient/Transcranial Magnetic Stimulation (TMS) Therapy.

The health plan denied the Mental Health/Outpatient/Transcranial Magnetic Stimulation (TMS) Therapy.  The health plan's determination is upheld.

The patient is a male with a diagnosis of major depressive disorder whose physician is requesting treatment with transcranial magnetic stimulation (TMS). The office visit progress note indicates that the patient has experienced depressive symptoms for years. He endorsed symptoms of low mood with hopelessness, low energy, trouble falling asleep or sleeping too much, poor appetite or overeating, and feeling badly about himself. He reported that in the past he would compensate with alcohol but had been sober for 8 weeks. He denied current suicidal ideation but stated at one point that he was looking for relief from suicidal ideation. He was currently prescribed Luvox 200 milligrams (mg) daily and Propranolol 10 mg as needed, both for 3-4 months, and Trazodone 50-100 mg at bedtime as needed, which he stated was effective but caused him some daytime drowsiness. He reported previous trials of Prozac, Zoloft, Effexor, Pristiq, Trintellix, and Seroquel, all of which were ineffective and were taken for 1 year. He also had brief trials of Remeron, Adderall, hydroxyzine, and possibly Lexapro. He is currently seeing a psychotherapist. He reported three previous inpatient psychiatric admissions, for alcohol use and suicidal ideation. The plan was to start treatment with TMS.

The health plan's determination is upheld, in whole.

No, the proposed health service or treatment TMS therapy is not likely to be more beneficial than any standard treatment(s) for the insured's life threatening or disabled condition or disease. Per health plan policy, the patient does not meet criteria for treatment with TMS. While the patient does have a diagnosis of major depressive disorder and has failed the required six to eight week trials of three antidepressants from at least two different antidepressant medication classes, the plan criteria states that TMS is considered experimental and investigational in patients who have an active and untreated substance use disorder within the previous six months. This is consistent with recommendations from the medical literature, which conclude that alcohol and other substance use can lower the seizure threshold and thus increase the likelihood of seizure occurrence during treatment with TMS. (DSM-V(TR) criteria) for early partial remission of alcohol use disorder as failure to meet criteria for alcohol use disorder for more than 3 months but less than 12 months. Since the patient has had 2 months of sobriety from alcohol, he does not meet criteria for early remission from alcohol use, and as such, is considered to meet continued criteria for active alcohol use disorder. For these reasons, the proposed treatment with TMS is not likely to be more beneficial than any standard treatment and is considered experimental/investigational in this patient. Neither the health plan policy nor the medical literature supports the use of TMS in this patient, due to his history of alcohol use 8 to 10 weeks ago.