Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder-Severe-Recurrent

Treatment: Repetitive transcranial magnetic stimulation therapy (TMS) for 31 sessions

 The insurer denied coverage for Repetitive transcranial magnetic stimulation therapy (TMS) for 31 sessions. The denial was upheld.

This patient is a female had depressive symptoms and a diagnosis of Major Depressive Disorder-Severe-Recurrent. She reportedly had multiple past antidepressant medication trials without reported sustained efficacy including trials of Sertraline, Fluoxetine, Escitalopram, Citalopram, Bupropion, Mirtazepine, Venlafaxine, and also tried Lithium, and had 2 past trials of psychotherapy. She reportedly responded to deep TMS (Transcranial magnetic stimulation therapy) in mid to late 2018 with Brainsway DTMS as she reportedly had 36 treatments and her Hamilton depression score went from 34 which is considered severe depression to 8.    It was reported that she had a recent relapse of depression as her Hamilton depression scale was 32 in mid-2019. The request was for TMS - transcranial magnetic stimulation therapy.

The insurer denied coverage for repetitive transcranial magnetic stimulation therapy (TMS)  for 31 sessions stating that she did not fail at least 2 trials of antidepressants at minimal doses and duration of treatment during the current treatment episode.

This reviewer agrees with the decision to deny coverage for repetitive transcranial magnetic stimulation therapy (TMS)  for 31 sessions as the FDA approved Neurostar Transcranial Magnetic Stimulation Therapy for the treatment of depression in October 2008 but it required failure of at least one antidepressant during the current treatment episode. It also stated that transcranial magnetic stimulation therapy was cleared by the FDA in 10/08 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. Neurostar TMS Therapy System was the largest multisite (23 centers) randomized sham controlled trial ever conducted with transcranial magnetic stimulation therapy. The APA Practice Guidelines for the Treatment of Major Depressive Disorders considers transcranial magnetic stimulation therapy as an appropriate acute phase option for patients who do not respond adequately to pharmacotherapy or psychotherapy and were considered treatment resistant.

In this case this patient had a documented diagnosis of Major Depressive Disorder which is an FDA approved diagnosis for transcranial magnetic stimulation therapy (TMS) treatment but she did not have reports of current antidepressant medication trials during the current major depressive episode in which she relapsed into depression in mid-2019.  This patient reportedly failed many past antidepressant medication trials without reported sustained efficacy including trials of Sertraline, Fluoxetine, Escitalopram, Citalopram, Bupropion, Mirtazepine, Venlafaxine during past major depressive episodes. In this case, there was no documentation that she failed one or two current antidepressant medication trials during the current major depressive episode. It did not appear that she met current criteria for either repetitive or deep TMS (transcranial magnetic stimulation therapy or lacked current antidepressant medication responses during this current major depressive episode as this was not documented in the medical records provided. It did not appear that she met criteria for either repetitive or deep TMS then. As a result, the recommendation is to uphold the previous decision and deny coverage for repetitive transcranial magnetic stimulation therapy (TMS) or deep TMS then. It appeared that the health care plan acted reasonably and with sound clinical judgment.

Based on the above, the medical necessity for Repetitive Transcranial Magnetic Stimulation (rTMS), 31 sessions (CPT codes 90867 and 90868) is not substantiated.  The insurer's denial is upheld.