Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested reimbursement and continued authorization and coverage for transcranial magnetic stimulation (TMS) therapy already provided and onward for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient is a 44-year-old female diagnosed with depression and anxiety.  There is no description of the specific symptom complex or any functional impairment that it might spawn.  In terms of psychiatric treatment, the patient has engaged in cognitive therapy, of which the frequency and duration is uncertain based on the documentation provided, and any other evidence based therapy trials for the treatment of major depressive disorder were not mentioned. It is unclear if the patient has required any inpatient, residential or partial hospitalization, or considered electroconvulsive therapy, for her long standing affective symptomatologies. The patient has trialed the following psychotropic medications:  citalopram, sertraline, bupropion, duloxetine, venlafaxine, and amitriptyline.  The specific dosages, frequencies, and duration of treatment, were not provided.  The only somatic augmentation strategy attempted was buspirone and there is no discussion of medications such as aripiprazole or quetiapine.  Medication management has not achieved remission.  In the past, the patient received five treatments of transcranial magnetic stimulation (TMS) therapy and a full course of 20 to 30 treatments of TMS has been recommended. The Health Plan has denied the request for reimbursement and coverage of past and future TMS therapy.Although this fairly new treatment technology lacks a robust heterogeneous evidence base at this early stage of implementation, the literature supporting TMS in terms of volume, quality and range of investigation continues to grow.  The efficacy of TMS may be greater than originally reported (Schutter, et al. and Gross, et al.), and researchers such as George, et al. and Demitrack and Thase are reporting more conclusive findings in well-developed studies.  Hippocampal neurogenesis has been demonstrated in trials using rats, which is a phenomenon commonly seen in psychotropic medication and electroconvulsive therapy and is representative of a promising expansion of the TMS research base (Ueyama, et al.).  These current observations notwithstanding, the data were convincing enough for TMS to earn Food and Drug Administration (FDA) clearance.  Subsequent to said clearance, the American Psychiatric Association (APA), investigated this treatment and the available literature and endorsed TMS for the acute phase treatment of major depressive disorder. Although the literature supports the use of TMS therapy in the treatment of depression, the documentation provided neither describes a symptom complex consistent with major depressive disorder, nor elaborates upon specific evidence based psychotherapies that have proved ineffective. Further, trusted and well-established medication management and augmentative strategies commonly used in the treatment of major depressive disorder are not described.  Therefore, the TMS therapy at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.