Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Major Depressive Disorder.
Treatment: continuation of transcranial magnetic stimulation sessions.
The insurer denied coverage for continuation of transcranial magnetic stimulation sessions.
The denial is overturned.

This patient had a diagnosis of Major Depressive Disorder and had reports of depressive symptoms including sad mood, pessimism, loss of interest and pleasure, suicidal thoughts, concentration problems, fatigue, worthlessness, indecisiveness, and self-criticism. He reportedly was approved for transcranial magnetic stimulation therapy (TMS) for 36 sessions but only had a partial response. The request was for an additional 15 sessions to try to better target depressive symptoms, improve functioning, and wellbeing. The patient still reportedly had a high score on the Beck Depression Inventory-II (BDI-II) with a score of 19. 
  
This reviewer disagrees with the decision to deny coverage for 15 additional transcranial magnetic stimulation therapy (TMS) services as this patient still had reports of depressive symptoms and had a partial response to the 36 transcranial magnetic stimulation therapy (TMS) treatments. There are some peers reviewed literature supporting the efficacy of additional TMS session in helping target depressive symptoms. According to the article " Transcranial Magnetic Stimulation in Acute Major Depressive Disorder: Clinical Response in Open Label Extension Trial" the conclusion of the open label study provides further evidence that TMS is effective in the treatment of Major Depressive Disorder. It also stated that continued active TMS provided additional benefit to some patients who failed to respond to 4 weeks of treatment suggesting that longer courses of treatment may confer additional therapeutic effects. This was the case with this patient as he had a partial response and appeared to require additional TMS sessions. Also, in a sham verses TMS treatment group, there was reports of 41.3 % (percent) response rate at week 12 compared to a response rate of 26.5 % at week 6. This indicates that in cases in which there are still depressive symptoms present after 6 weeks of TMS treatment, further treatment of TMS can yield improvement at week 12 with further TMS sessions. 

According to the article, "61% of Unmedicated Treatment Resistant Depressive Patients Who Did Not Respond to Acute TMS Treatment Responded after 4 weeks of twice weekly TMS in The Brainsway Pivital Trial" the conclusion was that a significant proportion of acute course non responders to TMS treatment eventually responded to continued treatment. It stated that continued TMS treatment beyond acute course for non-responders may result in eventual response in over half of these individuals. This is evidence in peer reviewed literature that additional TMS sessions may be helpful in treating patients with major depressive disorder who did not have a full response to the 36 TMS session and that there was improvement in health outcome. This patient appeared to be a good candidate for the additional TMS sessions as he was a partial responder and had a diagnosis of Major Depressive Disorder. This appeared to be the best available option at that time and appeared to be possibly more beneficial than other standard treatments, and it did not appear that adverse risks increased over standard treatments. The FDA (Food and Drug Administration) approved Neurostar Transcranial Magnetic Stimulation Therapy for the treatment of depression. Transcranial magnetic stimulation therapy was cleared by the FDA and indicated for the treatment of major depressive disorder in 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. 

The carrier's denial of the continuation of transcranial magnetic stimulation sessions should be overturned.