Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder
Treatment: Repetitive Transcranial Magnetic Stimulation (rTMS)
The insurer denied Repetitive Transcranial Magnetic Stimulation (rTMS). 
The denial is overturned.

The repetitive transcranial magnetic stimulation (rTMS) was medically necessary.

The patient is a female with a history of mental illness.  She is interested in pursuing TMS (transcranial magnetic stimulation) treatment for depression a new provider.

The patient has been diagnosed with major depressive disorder, single episode, severe without psychotic features.  She was previously treated with TMS in 2019 with 48 sessions.  She had been taking Sertraline 50 milligrams (MG) since 2019, Wellbutrin, and Vyvanse.  She previously took Prozac, Zoloft, Wellbutrin, Trazodone, Trintellix, Luvox, Lexapro, Seroquel, and Lamictal.

She was evaluated by the new provider and was noted to have a HAMD (Hamilton Depression Rating Scale) score of 42 and a Beck score of 53.  The new provider is a board-certified psychiatrist who recommended this treatment.  She received 36 TMS treatments with the new provider in 2020.  After that, she was noted to have a HAMD of eight and a Beck score of five.  She is noted to be "handling situations better because of the TMS."

The patient has a history of treatment refractory depression.  She has tried and failed many different medications.  The patient had treatment with rTMS previously, but with a different provider.  The patient was not satisfied with the application of treatment from that previous provider so she pursued the FDA-approved treatment for her condition - rTMS, with a new provider.  She received treatment that was provided by a board-certified psychiatrist who thought this was an appropriate treatment.  Her symptoms were very severe at the time of her initial evaluation and improved substantially with the treatment.  Severe depression places a patient at risk for hospitalization, suicidality, and self-injury.  

RTMS for this patient was medically necessary.  Although the patient had tried rTMS previously, it was reasonable to repeat this type of treatment as she was with a new provider and had found the previous provider unsatisfactory.  It was reasonable to repeat rTMS in this patient with treatment refractory depression and minimal other treatment options.  Per the standard of care in the psychiatry community, and because this patient has treatment refractory depression, initiating a new round of rTMS was medically necessary.  In addition, given that she was responding to the treatment, continued treatment for the full course was also medically necessary.  

The patient has a history of treatment refractory depression.  Severe depression places a patient at risk for hospitalization, suicidality, and self-injury.  She pursued an FDA-approved treatment for her condition.  She received treatment that was provided by a board-certified psychiatrist who thought this was an appropriate treatment.  Her symptoms were very severe at the time of her initial evaluation and improved substantially with the treatment.  Therefore, the full course of treatment should be covered.