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.  Medicare rules state that Medicare considers transcranial magnetic stimulation (TMS) therapy reasonable and necessary when it is furnished in accordance with the accepted standards of medical practice, when it is furnished in a setting appropriate to the patient's medical needs and condition, when it meets but does not exceed the patient's medical need and when it is ordered and furnished by qualified personnel. It is expected that TMS therapy will be ordered by, and furnished under, the direct supervision of a psychiatrist who has experience administering TMS therapy. TMS therapy not ordered by and furnished under direct supervision, by a psychiatrist will be considered not medically reasonable and necessary and not subject to coverage. Left Prefrontal repetitive TMS (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 four trials of psychopharmacologic agents in the current depressive episode from at least two different agent classes. At least one of the treatment trials must have been administered at an adequate course of mono- or poly-drug therapy; or - Inability to tolerate psychopharmacologic agents as evidenced by four 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. 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. 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 this psychiatrist (physician present in the area and immediately available, but does not necessarily personally provide the treatment).  You can find these rules in Local Coverage Determination (LCD) Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L36469).  The rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare Program Integrity Manual Chapter 3, Section 3.3.2.1.  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.