Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Noridian considers TMS therapy reasonable and necessary when it is furnished in
accordance with the accepted standards of medical practice, when it is furnished in a setting appropriate to the
patient's medical needs and condition, when it meets but does not exceed the patient's medical need and when
it is ordered and furnished by qualified personnel. It is expected that TMS therapy will be ordered by a
psychiatrist and furnished under the direct supervision of a qualified physician (MD or DO) who has
experience administering TMS therapy.
Initial Treatment
Left Prefrontal rTMS of the brain is considered medically necessary for use in an adult who meets all four of
the following criteria:
1. Has a confirmed diagnosis of severe major depressive disorder (MDD) single or recurrent episode; and
2. One or more of the following:
- Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically
significant response to a single trial of psychopharmacologic agents in the current depressive episode;
or
- Inability to tolerate psychopharmacologic agents as evidenced by two trials of psychopharmacologic
agents from two different agent classes; or
- History of response to rTMS in a previous depressive episode; or
- A history of response to ECT in a previous or current episode or an inability to tolerate ECT, or is a
candidate for, but has declined ECT and rTMS is considered a less invasive treatment option.
AND
3. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate
frequency and duration without significant improvement in depressive symptoms as documented by
standardized rating scales that reliably measure depressive symptoms.
AND
4. The order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the
patient and reviewed the record. The psychiatrist will have experience in administering TMS therapy. The
treatment shall be given under direct supervision of a qualified physician (physician present in the area and
immediately available but does not necessarily personally provide the treatment).
Therapeutic repetitive transcranial magnetic stimulation treatment; subsequent motor threshold redetermination
with delivery and management is considered reasonable and necessary when there is a change in
clinical status or medical regimen that is expected to alter cortical excitability. The medical record must clearly
document the rationale for the performance of a motor threshold redetermination.
You can find this rule in the Local Coverage Determination (LCD): Repetitive Transcranial Magnetic
Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L37088).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.