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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Grievance Manual, Section 50.12.1. 
 
The rules state that repetitive transcranial magnetic stimulation (rTMS) is only considered medically necessary 
in adults who have a confirmed diagnosis of major depressive disorder (MDD), single or recurrent episode and 
meet the following criteria: 
- One or more of the following: 
~ Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically 
significant response to one trial of psychopharmacologic agents in the current depressive 
episode from at least two different agent classes. Each agent in the treatment trial must have 
been administered at an adequate course of mono- or poly-drug therapy; or 
~ Inability to tolerate psychopharmacologic agents as evidenced by two trials of 
psychopharmacologic agents from at least two different agent classes, with distinct side effects; 
or 
~ History of response to rTMS in a previous depressive episode; or 
~ If patient is currently receiving electro-convulsive therapy, rTMS may be considered reasonable 
and necessary as a less invasive treatment option. 
- 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. 
- The order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the 
patient and reviewed the record. The physician will have experience in administering TMS therapy. The 
treatment shall be given under direct supervision of this physician (physician present in the area but 
does not necessarily personally provide the treatment). 
- Non-physician practitioners (NPPs) providers may order treatment (or retreatment) if it is within the 
scope of practice of the NPP in the State they are licensed. It is expected that the NPP has examined the 
patient, reviewed the record and has experience administering TMS therapy. The treatment shall be 
given under direct supervision of this NPP. 
- The rTMS treatment is delivered by a device that is FDA-approved or cleared for the treatment of 
MDD in a safe and effective manner. rTMS treatment should generally follow the protocol and 
parameters specified in the manufacturers user manual, with modifications only as supported by the 
published scientific evidence base. 
 
You can find these rules in Local Coverage Determination (LCD) Transcranial Magnetic Stimulation 
(L33398). 
 
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.