Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mood and anxiety symptoms; depressed mood
 
Treatment: Pre-service request for transcranial magnetic stimulation therapy

The insurer denied coverage for pre-service request for transcranial magnetic stimulation therapy. The denial is reversed. 

This patient is a female who had mood and anxiety symptoms including mood swings, depressed mood, chronic suicidal ideation, depersonalization, posttraumatic stress disorder (PTSD) symptoms, and obsessive compulsive symptoms including ruminating and obsessing. She had diagnoses of Major Depressive Disorder-Severe without psychotic symptoms, Borderline Personality Disorder, PTSD, Obsessive Compulsive Disorder, and Severe Cannabis Use Disorder.  She had past medication trials including Paxil, Duloxetine, Trazodone, Depakote, and Lyrica.  She had been in individual outpatient mental health treatment twice per week and also had group therapy.  She had Cognitive Behavioral Therapy (CBT) and Mentalization based therapy as well.  The request was for transcranial magnetic stimulation therapy (TMS) to help with obsessive compulsive symptoms. The insurer denied coverage for the pre-service request for transcranial magnetic stimulation therapy.

This reviewer disagrees with the decision to deny coverage for pre-service request for transcranial magnetic stimulation therapy (TMS) beginning on a specified date as the Food and Drug Administration (FDA) approved TMS for the treatment of Obsessive Compulsive Disorder in 2018.  Also, according to Clinical Psychiatric News October 2019 page 14, Deep Transcranial Magnetic Stimulation Lifts OCD Symptoms by Bruce Jancin, it states that high frequency deep transcranial magnetic stimulation directed at the anterior cingulate cortex and medial prefrontal cortex proved to be safe and effective nonpharmacological treatment for symptoms of obsessive compulsive disorder in an international random, sham controlled, double blind clinical trial that earned the device clearance from the Food and Drug Administration.  This was based on a 2018 multi-center study of 100 patients randomized to treat with the transcranial magnetic stimulation therapy (TMS) device and the results reported that 38% of the patients treated with the TMS device had greater than 30% reduction in obsessive compulsive symptoms as measured with the Yale-Brown Obsessive Compulsive Scale (YBOCS) compared to 11% in controls.  

This patient is a complex patient with multiple diagnoses including Major Depressive Disorder-Severe without psychotic symptoms, Borderline Personality Disorder, PTSD, Obsessive Compulsive Disorder, and Severe Cannabis Use Disorder.  The FDA approved Neurostar Transcranial Magnetic Stimulation Therapy for the treatment of depression in October 2008 and indicated for the treatment of Major Depressive Disorder in patients who failed or who did not have satisfactory improvement from one past antidepressant medication at or above minimal effective dose and duration in the current episode. Also, the FDA approved Brainsway H1 coil (deep TMS) in 2013 for Major Depressive Disorder in which one failed at least 2 antidepressant medications during the current treatment episode.  It also was FDA approved for obsessive compulsive disorder in 2018.   

As a result, reverse the previous decision and approve the pre-service request for transcranial magnetic stimulation therapy (TMS) beginning on a specified date.  The health care plan did not act reasonably, or with sound medical judgment, or in the best interests of the patient.

The carrier's denial of coverage for the pre-service request for transcranial magnetic stimulation therapy beginning on a specified date is reversed. The medical necessity is substantiated.