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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation.  Findings:  The physician reviewer found that Transcranial magnetic stimulation is a non-invasive intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population for those have failed at least one antidepressant medication trial.  Transcranial magnetic stimulation is not indicated at this time for other psychiatric conditions, such as bipolar illness, anxiety disorders or trauma-related disorders, and the data are mixed on its applicability for chronic depressiveness. According to a summary of transcranial magnetic stimulation treatment recommendations by Perera and colleagues, The standard parameter setprovided clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established.  The authors did suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. However, based on a starting date, the patient had already utilized this additional time frame during the dates of service in dispute.  Moreover, from the clinical perspective, the patient had no significant change in her validated rating scales during the first six weeks of treatment. Ordinarily, these scores would reduce, even modestly for a partial response, within this timeframe if the transcranial magnetic stimulation was providing therapeutic benefit.  Further, based on the documents provided, it is unclear if the patient had an adequate trial of an antidepressant medication during the episode of acute illness. Notwithstanding, the patient was prescribed an antidepressant medication, sertraline. Pro-serotonergic medications, such as sertraline, are first-line treatments for depression, anxiety and posttraumatic stress disorder, and may take up to six weeks, if not more, to achieve efficacy. The medication was increased to a therapeutic dose, and about two weeks later, there was a marked reduction in the symptom complex, including report of nonexistent suicidal ideation. Finally, it does not appear that the patient was active in a depression-focused, evidence-based psychotherapy, such as cognitive behavioral therapy, interpersonal therapy or psychodynamic therapy.   At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of transcranial magnetic stimulation therapy, particularly in cases where there is no clinical improvement during the first six weeks of treatment. Thus, the medical literature does not support a reasonable expectation that additional transcranial magnetic stimulation therapy at the time would have improved the patients condition or prevented a more serious episode of illness, while her improvement in mid-January 2018 may have been the result of interventions other than transcranial magnetic stimulation. In sum, transcranial magnetic stimulation was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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.