Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressing Disorder. 
Treatment: Transcranial Magnetic Stimulation (TMS). 

The insurer denied coverage for TMS. 
The denial is overturned. 

This is the case of an adult female with history of depressive symptoms including sad mood, suicidal ideation, feelings of hopelessness, poor sleep, low energy, and not feeling good for an entire day. She reported a long history of depression. The patient has a diagnosis of major depressive disorder- severe-recurrent type, generalized anxiety disorder, panic disorder, and attention-deficit hyperactivity disorder (ADHD). She reportedly was taking Escitalopram 25 mg (milligrams). She reportedly had tried Fluoxetine up to 60 mg with no response, Mirtazepine and had reported sedation, and had side effects to Bupropion including feeling wired, and also took intravenous (IV) Ketamine. The patient reportedly also took Quetiapine, Aripiprazole, Lamotrigine, Lithium, Topiramate, and Gabapentin. She also reportedly had  trials of weekly psychotherapy for years, as well as cognitive behavioral therapy, Eye Movement Desensitization and Reprocessing (EMDR) therapy, and phototherapy. The patient had a psychiatric evaluation who recommended transcranial magnetic stimulation (TMS) therapy. 
    
The Food and Drug Administration (FDA) approved NeuroStar TMS Therapy for the treatment of depression. TMS therapy was cleared by the FDA and indicated for the treatment of major depressive disorder in 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. NeuroStar TMS Therapy System was the largest multisite (23 centers) randomized sham-controlled trial ever conducted with TMS therapy. This was the principal study for the FDA's approval of TMS therapy for major depressive disorders. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Major Depressive Disorders considers TMS 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-severe recurrent which is an FDA approved diagnosis for TMS therapy treatment. She has tried and failed several antidepressant medications in different classes including Fluoxetine, a serotonin reuptake inhibitor, and it was an adequate dosage of 60 mg and adequate duration; Escitalopram, currently at a high dosage of 25 mg per day; Bupropion, which is a dopamine norepinephrine reuptake inhibitor, which is FDA approved for major depressive disorder, and she reportedly had a side effect of feeling wired; and Mirtazepine which has a unique mechanism of increasing serotonin and norepinephrine, and she took it. She also tried ketamine for depression. This is more than an adequate trial of antidepressant medications. She also reportedly took Quetiapine, Aripiprazole, Lamotrigine, Lithium, Topiramate, and Gabapentin which are mood stabilizers. She also had 2 trials of weekly psychotherapy for years, cognitive behavioral therapy, EMDR, and phototherapy. 

The standard recommendation for TMS therapy 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. The patient was considered a candidate for TMS therapy treatment, and it was considered medically necessary treatment and also is an FDA approved treatment for her diagnosis. 

The health care plan did not act reasonably, with sound clinical judgment, or in the best interests of the patient. The medical records provided enough specific evidence to support the medical necessity for TMS.

The insurer's denial of coverage for the Transcranial Magnetic Stimulation (TMS) is overturned. Medical necessity is substantiated.