Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder-severe.
Treatment transcranial magnetic stimulation (TMS).
The insurer denied coverage for transcranial magnetic stimulation (TMS).
The denial is overturned.

The patient had depressive symptoms including depressed mood, no interest, motivation, or pleasure, apathy, sleeping problems, absent mindedness, maladaptive daydreaming, dissociations, and panic attacks. She was noted to have diagnoses of Major Depressive Disorder-severe, Generalized Anxiety Disorder, and Social Phobia. She reportedly had a history of these depressive symptoms, as well as past picking behavior. She had past antidepressant trials of Lexapro 20 mg (milligrams), Prozac 60 mg, Effexor 75 mg, and Trazodone 100 mg. She also took Buspirone and Clonazepam. She had past psychiatric treatment with another psychiatrist and also past DBT (dialectical behavioral therapy) and PHP (partial hospitalization program) treatment prior to this psychiatric treatment. The recommendation from the treating psychiatrist was for transcranial magnetic stimulation therapy (TMS) treatment with 36 sessions. 

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; it is 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. This was the principal study for the FDA's approval of transcranial magnetic stimulation therapy for major depressive disorders.

The standard recommendation for TMS treatment is for 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 standard amount is typically 36 sessions of TMS to start, which was the provider's request. It is not a requirement and not considered medically necessary for the treating provider to collaborate with other providers prior to TMS treatment.

In this case, the patient had a documented diagnosis of Major Depressive Disorder-severe, which is an FDA-approved diagnosis for TMS treatment She had tried and failed several antidepressant medications in different classes including Fluoxetine at a high dose of 60 mg per day and Lexapro at 20 mg which is the maximum FDA approved dose; these are serotonin reuptake inhibitors. The patient also reportedly took a serotonin norepinephrine reuptake inhibitor, Effexor 75 mg, and another antidepressant Trazodone, which is another class. This was 100 mg, and so the patient had adequate trials of several antidepressants from 3 different classes with lack of efficacy. Also, it was reported that the patient's current episode was for several years; the patient had lack of efficacy with adequate trials while in the same major depressive episode. 

TMS is an FDA approved treatment for the patient's diagnosis of Major Depressive Disorder. The patient was a candidate for TMS treatment, which was considered medically necessary treatment. The medical records provided enough specific evidence that 36 sessions of TMS was medically necessary treatment.

The health care plan did not act reasonably and with sound medical judgement or in the best interest of the patient.

The insurer's denial of coverage for transcranial magnetic stimulation (TMS) is overturned. Medical necessity is substantiated.