Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obsessive-compulsive disorder, generalized anxiety disorder, and major depressive disorder.
Treatment: Transcranial Magnetic Stimulation (TMS).
The insurer denied: Transcranial Magnetic Stimulation (TMS).
The denial is overturned.

The patient is an adult female diagnosed with recurrent and severe major depressive disorder without psychotic features and treatment refractory depression. The patient is also diagnosed with co-morbid generalized anxiety disorder and obsessive-compulsive related disorder (OCD). The patient has a documented history of multiple medication treatments for depressive disorder including treatment with Luvox, Prozac, and Zoloft with consideration of the use of clomipramine. The patient received augmentation treatment with Deplin and Abilify without benefit. Symptoms of depression have included depressed mood and sad affect with loss of interest or anhedonia, low energy with fatigue, concentration problems and associated symptoms of anxiety. PHQ (patient health questionnaire)-9 scale was scored at 18 in the moderately severe to severe range of depression. There is ongoing weekly psychotherapy with CBT (cognitive behavioral therapy) for the past 3 months. The patient's clinician recommended a course of repetitive transcranial magnetic stimulation (rTMS) therapy with a clinically appropriate number of sessions in order to address the primary diagnosis of major depressive disorder and treatment resistant/refractory depression. The health plan has denied authorization for coverage of TMS (transcranial magnetic stimulation) therapy as not medically necessary on the basis of plan guidelines and indicates that the requested treatment is not a covered benefit with reference to the plan policy pertaining to TMS (transcranial magnetic stimulation). The denial determination indicated that the use of TMS (transcranial magnetic stimulation) in the treatment of OCD (obsessive compulsive disorder) and anxiety is considered experimental and investigational or unproven. The appeal asserts that the patient is appropriately diagnosed with treatment refractory major depressive disorder, and that comorbid conditions were not a focus of treatment with regard to TMS (transcranial magnetic stimulation) therapy. However, the appeal references the literature that supports the use of TMS (transcranial magnetic stimulation) in the treatment of OCD (obsessive compulsive disorder) and notes that OCD (obsessive compulsive disorder) is an indication for OCD (obsessive compulsive disorder), as well as treatment resistant depression. The appeal also indicates that the plan criteria are met in this case for TMS (transcranial magnetic stimulation) treatment of depression.

The health plan should cover the transcranial magnetic stimulation. 

The request for coverage of TMS (transcranial magnetic stimulation) therapy is reasonable and clinically appropriate in this case scenario. Repetitive TMS (transcranial magnetic stimulation) therapy as a primary or adjunctive therapy for treatment of depressive disorder has generally been evaluated in patients who have treatment refractory depression, as defined by one or more, antidepressant medication treatment failures with or without augmentation. TMS (transcranial magnetic stimulation) therapy for depressive disorder has been established by the FDA (United States Food and Drug Administration) as a safe treatment. The data, as reflected in peer reviewed medical literature, supports this assertion. Specifically, when treatments with antidepressant medication with or without augmentation, and/or electroconvulsive therapy, and/or psychotherapy, especially cognitive behavioral therapy, have failed, then TMS (transcranial magnetic stimulation) may be an appropriate consideration. This assertion is also noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder.