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 state that left prefrontal transcranial magnetic stimulation (TMS) of the brain is considered medically 
necessary for use in an adult who meets 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: 
 The patient has demonstrated resistance to treatment with psychopharmacologic agents as evidenced by 
a lack of clinically significant response to four trials of such agents, in the current depressive episode, 
from at least two different agent classes. (At least one of the treatment trials must have been 
administered as an adequate course of mono- or poly-drug therapy; antidepressants involving standard 
therapeutic doses of at least 4 weeks duration); or 
 Inability to tolerate psychopharmacologic agents as evidenced by four trials of psychopharmacologic 
agents with distinct side effects; or 
 History of response to TMS in a previous depressive episode; (evidenced by a greater than 50% 
improvement in a standard rating scale for depression symptoms); or 
 Is currently receiving or is a candidate for and has declined electroconvulsive therapy (ECT) and TMS 
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. 
The attending physician must use evidence-based validated depression monitoring scales such as the Geriatric 
Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression 
Scale (BDI) Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating 
Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive 
Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission 
of symptoms. 
 
Limitations 
The following cautionary uses have not been proven in clinical studies and on post payment medical review of 
the records may be determined to be not medically necessary and denied.  Seizure disorder or any history of seizure (except those induced by ECT or isolated febrile seizures in 
infancy without subsequent treatment or recurrence); 
 Presence of acute or chronic psychotic symptoms or disorders (such as schizophrenia, schizophreniform 
or schizoaffective disorder) in the current depressive episode; 
 Neurological conditions that include epilepsy, cerebrovascular disease, dementia, increased intracranial 
pressure, having a history of repetitive or severe head trauma, or with primary or secondary tumors in 
the central nervous system (CNS); 
 Presence of an implanted magnetic-sensitive medical device located less than or equal to 30 centimeters 
from the TMS magnetic coil or other implanted metal items, including but not limited to a cochlear 
implant, implanted cardioverter defibrillator (ICD), pacemaker, vagus nerve stimulator (VNS), or metal 
aneurysm clips or coils, staples, or stents. (Note: Dental amalgam fillings are not affected by the 
magnetic field and are acceptable for use with TMS). 
TMS is reasonable and necessary for up to 30 visits over a 7-week period followed by 6 tapered treatments. 
Repeat acute treatment for relapse of depressive symptoms is considered medically necessary if the patient 
responded to prior treatments, specifically > 50% improvement in a standard rating scale for depressive 
symptoms (e.g., (GDS), PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR score). 
If patient meets the relapse criteria, up to 30 visits for the acute phase treatment followed by an additional 6 
visits for tapering is considered reasonable and necessary. 
The use of TMS as a maintenance therapy is not supported by controlled clinical trial at this time and is 
therefore, considered not reasonable and necessary. It is reasonable and necessary to report the treatment 
planning service once per course of treatment. You can find this rule at Centers for Medicare and Medicaid 
Services, Local Coverage Determination (LCD) L34522, Transcranial Magnetic Stimulation for Major 
Depressive Disorder. 
 
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.