Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Treatment-Resistant Depression. 
Treatment: Transcranial Magnetic Stimulation (TMS). 

The insurer denied: Transcranial Magnetic Stimulation (TMS). 
The denial is overturned. 

The patient is an adult male with a diagnosis of major depressive disorder, recurrent and severe without psychotic features and treatment resistant depression. The patient has a documented history of multiple medication treatments for depression including treatment with two antidepressants with disparate mechanism of action and at least four or more trials with antidepressant medications (fluoxetine, escitalopram, sertraline, duloxetine, and bupropion), as well as augmentation of the bupropion with quetiapine and supplemental use of clonazepam to address severe symptoms of anxiety and insomnia. Due to adverse effects or lack of efficacy, the patient continued to experience severe symptoms of depression and functional impairments that impact quality of life and day-to-day responsibilities. Additionally, the patient had ongoing treatment with cognitive behavioral therapy and past treatment with dialectical behavioral therapy (DBT) provided by a skilled and certified therapist. Comorbid psychiatric conditions include posttraumatic stress disorder (PTSD) and generalized anxiety disorder. The patient has reportedly not had psychiatric hospitalization or suicide attempts or suicidal behavior, but has been treated with partial hospitalization program (PHP) level care, as well as outpatient mental health treatment when he had the onset of his mood, anxiety and trauma-related disorders when he was younger. The Patient Health Questionnaire (PHQ)-nine (9) score was 20 reflecting severe depression at the time of initial evaluation for transcranial magnetic stimulation (TMS) therapy, and a Generalized Anxiety Disorder scale (GAD7) score of 19 reflecting severe anxiety. The patient's clinician initially deferred transcranial magnetic stimulation (TMS) treatment, but subsequently recommended treatment with a course of repetitive transcranial magnetic stimulation (rTMS) therapy with the usual treatment with up to 36 treatment episodes to include 30 sessions with six tapering sessions. The health plan has denied authorization for coverage of transcranial magnetic stimulation (TMS) on the basis of coverage exclusion and indicates that the requested treatment is not a covered benefit with reference to the plan's Medical Policy - Transcranial Magnetic Stimulation (TMS) for Treatment Resistant Depression. 

The requested health service, transcranial magnetic stimulation (TMS) services, is medically necessary. 

Per the health plan documents and submitted information, transcranial magnetic stimulation services are clinically appropriate and considered medically necessary as an adjunct and augmentation of the patient's antidepressant regimen in order to achieve a remission of symptoms related to severe major depressive disorder in the context of treatment refractory/resistant depression and failed trials with at least four antidepressants including antidepressant medications with disparate mechanisms of action and at least one appropriate augmentation strategy. Moreover, the coverage of transcranial magnetic stimulation services for a patient who meets criteria for treatment refractory depression and who is a reasonable candidate for the requested benefit of transcranial magnetic stimulation should be approved in this case scenario. Transcranial magnetic stimulation therapy for the treatment of major depressive disorder is a well-established treatment that is proposed for this patient in keeping with prevailing standards of medical practice for the condition under treatment in this case. The comorbid conditions do not contraindicate the use of transcranial magnetic stimulation, and the patient had past trials with combined treatments with evidence-based psychotherapy (CBT).