Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Transcranial magnetic stimulation (TMS) services (codes 90867, 90868)
The insurer denied coverage for TMS services (codes 90867, 90868)
The denial is overturned

This patient had depressive symptoms including sad and irritable mood, suicidal ideation, hopelessness and worthlessness, guilt, decreased energy, anhedonia, increased appetite, sleeping problems, concentration problems, isolation, and had a diagnosis of Major Depressive Disorder-severe-recurrent. His depressive symptoms were severe, and his Beck Inventory Scale II revealed a score of 31 which also is considered severe. It was reported that his symptoms interfered with his ability to function daily. He had past psychotherapy trials and past multiple medication trials with antidepressants including Prozac for approximately 23 years with lack of sustained efficacy, Wellbutrin for 1 year with a dosage of 300 milligrams (mg) with lack of sustained efficacy, Cymbalta for approximately 4 years with a dose of 60 mg with lack of sustained efficacy, Elavil over 48 years ago with reports of adverse effects, and Trazodone for 2 years and discontinued 28 years ago. He was treated with TMS treatments.

The medical records provided enough specific evidence that he required this treatment as he had a reported diagnosis of Major Depressive Disorder-severe-recurrent and had treatment resistant depression and he still had reports of severe depression even after taking multiple antidepressant medications. His Patient Health Questionnaire (PHQ-9) was 31 which is indicative of severe depression as per notes. The Food and Drug Administration (FDA) approved Neurostar TMS Therapy for the treatment of depression in October 2008. Neurostar TMS Therapy System was the largest multisite (23 centers) randomized sham-controlled trial ever conducted with TMS therapy. In addition, 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 with active severe depressive symptoms including sad and irritable mood, suicidal ideation, hopelessness and worthlessness, guilt, decreased energy, anhedonia, increased appetite, sleeping problems, concentration problems, and isolation. He also reportedly had past psychotherapy trials and past multiple medication trials with antidepressants. This is sufficient evidence to support that he had adequate antidepressant trials and even had different classes of medications including serotonin reuptake inhibitor, serotonin norepinephrine reuptake inhibitor, tricyclic antidepressant, and a dopamine norepinephrine reuptake inhibitor. He had adequate durations of trials and adequate dosages. He also had a trial of psychotherapy without prolonged efficacy. The standard recommendation for TMS 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 and this patient met that criteria as he tried multiple antidepressant medications from different classes of medications also. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.