Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
(TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management 
(90867), TMS treatment; subsequent delivery and management, per session (90868) and TMS treatment; 
subsequent motor threshold redetermination with delivery and management (90869). 
 
You asked the Plan to pre-approve TMS treatment. You say that the requested procedure is medically 
necessary due to major depressive disorder. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for approval. We reviewed her records, and they show major depression. The record sent 
by the provider indicates this is a request for continuation of rTMS, however there is no documentation that 
you responded to previous treatments of rTMS. The record indicated you have been in psychotherapy weekly 
since April 2017, and have tried Lexapro, Geodon, Wellbutrin, and Zoloft. Of these, you are currently taking 
Lexapro. You have declined treatment with electroconvulsive therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve TMS treatment. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on review of the records provided and utilizing the Medicare local coverage 
determination, it specifically states the confirmation of the diagnosis of severe major depressive disorder single 
or recurrent and one or more of the following, the patient has demonstrated resistance to treatment with 
psychopharmacologic agents as evidenced by lack of clinically significant response to for trials of such agents, 
in the current depressive episode from at least 2 different agent classes or the inability to tolerate 
pharmacologic agents is evidenced by 4 trials of psychopharmacologic agents with distinct side effects or 
history of response to Transcranial Magnetic Stimulation (TMS)  in a previous depressive episode evidenced 
by greater than 50 percent improvement in the standard rating scale or is currently receiving or is a candidate 
for and has declined electroconvulsive therapy and TMS is considered a less invasive treatment option and a 
trial of evidence-based psychotherapy known to be effective in the treatment of major depressive disorder of an 
adequate frequency and duration without significant improvement in depressive symptoms as documented by 
standardized rating scales. Based on the information provided, the enrollee does not meet the clinical criteria 
for the use of TMS therapy utilizing LCD (L33398) as she does not meet the severity of illness to require this 
type of treatment. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including 
cortical mapping, motor threshold determination, delivery and management (90867), TMS treatment; 
subsequent delivery and management, per session (90868) and TMS treatment; subsequent motor threshold 
redetermination with delivery and management (90869).