Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression.
Treatment: Transcranial Magnetic Stimulation (TMS).

The insurer denied: Transcranial Magnetic Stimulation (TMS).  The denial is overturned.

The patient is a young adult female with a diagnosis of major depressive disorder, recurrent and severe without psychotic features and treatment resistant depression. The patient has a documented history of multiple medication treatments for depression including treatment with two antidepressants with disparate mechanism of action and at least four or more trials with antidepressant medications including escitalopram, trazodone, desvenlafaxine and bupropion resulting in lack of effectiveness or intolerance. The patient continued to experience severe symptoms of depression and functional impairments that impact quality of life and day-to-day responsibilities. Additionally, the patient had ongoing treatment with cognitive behavioral therapy (CBT). There is no mention of comorbid psychiatric conditions or co-occurring substance use disorder. The current episode of depression began approximately 4 years ago. 

Mental status examination reveals depressed mood, sad affect, and anhedonia. The patient showed loss of interest and low energy and other neuro-vegetative disturbances related to depression, including insomnia. The patient's Patient Health Questionnaire-Nine (PHQ-9) score of 20 reflected severe depression at the time of initial evaluation for transcranial magnetic stimulation (TMS) therapy.

Coverage of the transcranial magnetic stimulation (TMS) therapy is requested on the basis of the clinical features and treatment history with treatment refractory depression and a primary diagnosis of severe and recurrent major depressive disorder. The appeal asserts that the plan guidelines and criteria are met in this case. The recommendation is in the context of an ongoing episode of severe depression that is treatment-resistant/refractory with failed treatment trials of medications combined with psychotherapy.

The health plan has denied authorization for coverage of transcranial magnetic stimulation (TMS) on the basis of coverage exclusion and indicates that the requested treatment is not a covered benefit with reference to the plan's Medical Policy- Transcranial Magnetic Stimulation. The denial determination indicated that the patient had no report of receiving psychotherapy and had not taken enough medication to justify transcranial magnetic stimulation therapy. 

The proposed treatment is medically necessary for this patient.

Per the health plan documents and submitted information, transcranial magnetic stimulation services are clinically appropriate and considered medically necessary as an adjunct and augmentation of the patient's antidepressant regimen in order to achieve a remission of symptoms related to severe major depressive disorder in the context of treatment refractory/resistant depression and failed trials with at least four antidepressants including antidepressant medications with disparate mechanisms of action. Moreover, the coverage of transcranial magnetic stimulation services for a patient who meets criteria for treatment refractory depression and who is a reasonable candidate for the requested benefit of transcranial magnetic stimulation should be approved in this case scenario; the requested transcranial magnetic stimulation therapy proposed is in the best interest of the patient and reflects sound medical judgment with respect to the use of the requested treatment. Transcranial magnetic stimulation therapy for the treatment of major depressive disorder is a well-established treatment that is proposed for this patient in keeping with prevailing standards of medical practice for the condition under treatment in this case. Additionally, the patient had past trials that included combined medication treatments with evidence-based psychotherapy (CBT).