Diagnosis: Depression.
Treatment: Transcranial Magnetic Stimulation (TMS).

The insurer denied transcranial magnetic stimulation.
The health plan's determination is upheld.

The patient has a diagnosis of persistent mood disorder and depersonalization-derealization syndrome. The patient has a history of worsening and persistent symptoms of depression despite past treatments with antidepressant and anxiolytic medications combined with psychotherapy. The patient's symptoms have persisted with deterioration in his functioning which include a medical leave of absence from college. The patient was subsequently referred for consideration of repetitive transcranial magnetic stimulation (RTMS) therapy for thirty-six treatment sessions with tapering over a three-week time frame per protocol. The referral also includes the use of functional magnetic resonance imaging (FMRI) which is a guided transcranial magnetic stimulation (TMS) with brain mapping. The patient did not have severe symptoms such as psychosis, cognitive impairment, perceptual disturbance or suicidal ideation. The patient is noted to have a loss of reality with chronic dissociation, as well as a persistent mood disorder. The patient has no reports of substance use disorder or other mental disorders. The patient has reportedly not been provided treatment with electro-convulsive therapy (ECT) and documentation does not note whether cognitive behavioral therapy (CBT) or other evidence-based psychotherapy is ongoing or has been provided by a skilled and certified therapist. Medication trials included the following: Buspar 10 milligrams (mg), Wellbutrin 150 mg, Prozac 20 mg, Zoloft 25 mg, Lamictal 25 mg and Seroquel 25 mg with the latter prescribed for insomnia and anxiety.

The health plan denied authorization for coverage of TMS on the basis of coverage exclusion and InterQual Criteria and indicated that the requested treatment is considered as not medically necessary because the patient's diagnosis does not warrant treatment with TMS. There is no standardized assessment for depression.
At issue is the medical necessity for the requested health service/treatment of transcranial magnetic stimulation (TMS).

The requested health service/treatment of transcranial magnetic stimulation (TMS), 36 units is not medically necessary for this patient.

Standard of care approaches for the treatment or mood disorder include combination therapy or an established augmentation therapy, as well as specific forms of psychotherapy that would establish that a patient's treatment is refractory. This patient's diagnosis of a treatment resistant depression and the severity of the depressive disorder is not well established. There is no standardized assessment for depression. Medical necessity is not met. This answer is consistent with practice guidelines referenced below, and the scientific literature pertaining to TMS therapy for major depressive disorder.