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 Retreatment may be considered for patients who met the guidelines for initial treatment and
subsequently developed relapse of depressive symptoms as evidenced by a 50% worsening in the prior best
response using the same rating scale (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR scores).

Patients must have responded to prior treatments as evidenced by a greater than 50% improvement in standard
rating scale measurements for depressive symptoms. (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS or
IDS-SR scores).

Coverage Limitations

TMS therapy not ordered by a psychiatrist who has experience administering TMS therapy and furnished under
direct supervision, by a qualified physician (MD or DO), will be considered not medically reasonable and
necessary and not subject to coverage.

The treatment must be provided by use of a device approved by the FDA for the purpose of supplying
Transcranial Magnetic Stimulation.

The benefits of TMS use must be carefully considered against the risk of potential side effects in patients. The
use of TMS in patients with any of the following is considered not medically reasonable and necessary and will
not be covered:

Seizure disorder or any history of seizures (except those induced by ECT or isolated febrile seizures in
infancy without subsequent treatment or recurrence) or any condition or treatment that may lower the seizure
threshold; or
Presence of acute or chronic psychotic symptoms or disorders (such as schizophrenia, schizophreniform or
schizoaffective disorder) in the current depressive episode; or
Neurological conditions that include epilepsy, cerebrovascular disease, dementia, increased intracranial
pressure, history of repetitive or severe head trauma, or primary or secondary tumors in the central nervous
system, or
Presence of an implanted magnetic-sensitive medical device located less than or equal to 30 cm from the
TMS magnetic coil or other implanted metal items including, but not limited to a cochlear implant, implanted
cardiac defibrillator (ICD), pacemaker, Vagus nerve stimulator (VNS), or metal aneurysm clips or coils, staples
or stents.
All other uses of Transcranial Magnetic Stimulation, including "maintenance therapy", "continuous therapy",
"rescue therapy" and "extended active therapy" are considered investigational and experimental as they are not
supported by controlled clinical trials and they are considered not reasonable and necessary. This noncoverage
is extended to any other terminology that may be given to a treatment episode that does not meet the
defined requirements noted and defined as initial treatment or retreatment.

Retreatment that occurs in close temporal proximity to a previous episode of treatment may be considered
maintenance therapy or continuous therapy and not reasonable and necessary. It is expected that the time
between treatment episodes should allow for assessment, both clinically and by one or more standard rating
scales, to clearly document that the patient responded and then relapsed. The number of retreatments is not
limited at this time. However, frequent reporting of services may trigger focused medical reviews.

All other uses of TMS therapy are investigational and/or experimental and are not covered.

Routine performance of motor threshold re-determination during rTMS therapy will be considered not
reasonable and necessary. More than three motor threshold redeterminations in a rolling six-month period will
be denied. Denied claims may be appealed with supporting documentation addressing the medical necessity
(e.g. when there is a change in clinical status or medical regimen that is expected to alter cortical excitability).

You can find this information in Medicare's Local Coverage Determination (LCD): Repetitive Transcranial
Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L37086).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.