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 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.  Resistance to treatment is defined by a failure to achieve a 50% reduction in depressive symptoms, in accordance with objective measures such as Geriatric Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression Inventory (BDI), the Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS), the Inventory for Depressive Symptomatology Systems Review (IDS-SR) or Hamilton Rating Scale for Depression (HAM-D), from a pharmacologic trial where the medication is administered at both an adequate dose and for an adequate period of time consistent with accepted standards of care.  A dose will be considered adequate when the medication is administered consistent with the FDA label. Where starting dosage is lower than maximum recommended dosage, the dose of any medication will be considered adequate when an initial response failure is followed by titrating the dosage upwards towards the maximum recommended dosage. Where such titration does not occur, the record must document the rationale for the decision not to increase the dose.   Duration of therapy will be considered adequate, when a particular medication is administered for a length of time consistent with expectations for expected response times for that medication or class of medications as defined in the medical literature supporting the efficacy of that medication or medication class and by the standard of care. Psychopharmacologic agent side effects will be considered intolerable, when those side effects are of a nature where they are not expected to diminish or resolve with continued administration of the drug.  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). NOTE: Please refer to the "Provider Qualification" section for qualified physician and direct supervision requirements. Therapeutic repetitive transcranial magnetic stimulation treatment; subsequent motor threshold re-determination 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.    Retreatment  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).  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 (L37088).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.