Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) treatment received 6/20/18 through 8/10/18. The Health Plan has denied this request indicating that the treatment at issue was not medically necessary for treatment of the enrollees severe depression. A review of the record indicates that the enrollee has been diagnosed with severe depression. In a report dated 6/20/18, the enrollees provider noted that the enrollee endorsed a history of depression for approximately 25 years. The enrollee reported poor energy, poor appetite, poor focus, lack of motivation, severe anhedonia, feelings of hopelessness, guilt/shame, negative thinking, and history of passive suicidal ideation. The enrollee had been treated with Prozac, Wellbutrin, Elavil, Pamelor, Trintellix, Abilify, Risperidone, Saphris, and Latuda. A report dated 8/10/18 noted the enrollee had received 36 transcranial magnetic stimulation sessions. A Patient Health Questionaire-9 (PHQ-9) score was noted to be 18 at baseline and 8 at week seven of transcranial magnetic stimulation treatment. The enrollees provider had recommended transcranial magnetic stimulation from 6/20/18 through 8/10/18 for the enrollee.At issue in this case is whether the transcranial magnetic stimulation (TMS) treatment at issue received 6/20/18 through 8/10/18, was medically necessary for treatment of the patients behavioral health condition. The patients depression is treatment resistant i.e. multiple antidepressants and augmentation strategies had not successfully brought on remission. Schutter reported that TMS had a moderate effect on treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provide evidence that TMS is a safe and effective treatment for major depressive disorder. The American Psychiatric Association Practice Guidelines for treatment of depression state that the (A) cute phase treatment may include TMS. Although TMS is relatively new, it is an effective treatment (as demonstrated in the referenced evidence-based literature). TMS is widely practiced throughout the country. TMS has been granted a category I CPT code by the American Medical Association and, is Food and Drug Administration approved for the treatment of treatment-resistant major depressive disorder consistent with standards of good medical practice in the United States. The patient had failed treatment with multiple medications and augmentation strategies. In this case, TMS for treatment of the patients treatment resistant major depression was medically necessary. Final Result: The reviewer determined that the requested treatment was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.