Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for transcranial magnetic stimulation (TMS) (36 sessions). While TMS is efficacious and well tolerated in adults with major depressive disorder (MDD), the potential utility of TMS in adolescents with treatment-resistant depression is based on case reports and unblinded studies with a relatively small sample size of patients. Researchers found that while preliminary data suggest that repetitive TMS (rTMS) may be efficacious for pediatric depression, randomized controlled trials that examine both short and long-term outcomes are needed before definitively recommending rTMS for adolescents with refractory depression. Likewise, medical literature shows that while a single center, open trial suggests that rTMS is a safe and effective treatment for youth with treatment-resistant MDD, larger randomized controlled trials are needed. Additional literature states that systematic data on the safety of TMS in children and adolescents are lacking, and that at present, there are many unknowns regarding the optimal stimulation parameters and potential biomarkers for depressed adolescents receiving TMS. They also indicated consideration should be taken regarding the neurodevelopment and unknowns associated with TMS exposure in adolescents. In a multicenter, double-blinded, randomized sham-controlled trial of TMS for treatment-resistant depression in adolescents, researchers found no statistically significant differences in clinical outcomes between the active TMS and sham TMS groups. Researchers also note that evidence on the efficacy of rTMS in adolescent depression is scanty, with many limitations, and that while the safety profile of rTMS for adolescent depression appears to be desirable, many parameters, including the most favorable approaches, have yet to be determined. Studies of TMS in the treatment of adolescent psychiatric disorders is largely focused on depression and relatively limited. Studies on the use of TMS to treat other pediatric psychiatric conditions such as attention deficit hyperactivity disorder (ADHD), autism, or obsessive compulsive disorder (OCD) are even more limited. Given that the efficacy of TMS for the treatment of depression and other psychiatric conditions in adolescents has not yet been established, the requested services are not medically indicated. In this patients case, TMS is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, TMS (36 sessions) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.