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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for transcranial magnetic stimulation (TMS). The enrollee has anxiety, recurrent severe major depressive disorder (MDD), severe obsessive compulsive disorder (OCD), and panic disorder. The enrollee reported social interactions and school can be very stressful; life in general is always worrisome and his mind does not stop worrying. His psychiatrist performed a transcranial magnetic stimulation (TMS) evaluation and recommended TMS per protocol for MDD with obsessional features. The enrollee has been struggling with severe depression and has utilized antidepressants unsuccessfully in the past. Use of repetitive TMS for treatment of resistant or refractory depression is consistent with treatment guidelines from a professional society. In addition, TMS is indicated for individuals who responded to a prior course of TMS. Prior to repetitive TMS treatment, the person requires an assessment to verify a primary diagnosis of treatment-resistant depression and a determination of whether the intervention can be used safely. The assessment includes a psychiatric history and mental status examination, with emphasis upon depressive symptoms, length of the current depressive episode, types and number of failed treatments during the present episode, and the number, length, and treatment history of prior depressive episodes. A general medical history and physical examination are performed, along with any necessary laboratory tests and neuroimaging studies that are indicated by the history and physical. The medical work-up should emphasize risk factors for seizures and preexisting neurologic disease, such as epilepsy, intracranial masses, and vascular abnormalities. The information regarding previous medication trials, though important, is self-reported. The reported failure of two antidepressants occurred during adolescence. There are no previous evaluations or follow-up notes from the providers who were evaluating and prescribing the medications. The enrollee has been using marijuana since age 16. He was using it daily until about one month prior to the TMS evaluation.  Cannabis use disorder can produce episodic or chronic mood changes or thought disturbances that may resemble non-drug-related psychiatric disorders; such as persistent depressive disorder (dysthymia), generalized anxiety disorder, delusional disorder, or schizophrenia, paranoid type. There is no information about how and if this was considered when treatment and response, or lack of response, to treatment for depression was evaluated with the prior medical management trials. Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition