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 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 at least 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 (see Retreatment[s] below for previous 
response criteria); 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 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 (TMS) 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. 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 (L34998). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.