Diagnosis: Depression
Treatment: Transcranial magnetic stimulation (TMS) treatments
The insurer denied the Transcranial magnetic stimulation (TMS) treatments.
The determination is overturned.

The patient has a history of opioid use on methadone maintenance, post-traumatic stress disorder (PTSD), Panic Disorder, obsessive-compulsive disorder (OCD), anxiety and depression. A request has been made for approval of transcranial magnetic stimulation (TMS) treatments. The request was previously denied due to inadequate medication trials; plan criteria state failure of 6-8 week trial of maximum tolerated pharmacological dosage to include one of the following: at least three antidepressants from at least two different antidepressant medication classes or at least two different antidepressants from at least two different antidepressant medication classes plus an augmenting agent, during the most recent episode of depression. At issue is the medical necessity of TMS.

The requested health service/treatment of TMS is medically necessary for the patient.
The patient's episode of depression have lasted for approximately 10 years. Additional documentation provided indicates that patient has trialed three different antidepressants from two different classes of medication, in addition to an augmenting agent. In particular, she has had trials of Lexapro 20 milligrams (mg), Celexa 40 milligrams (mg) and Effexor 225 milligrams (mg) which would qualify as three different medications trialed at adequate doses from two different classes. The Patient Health Questionnaire (PHQ) 9 score was 20 and the General Anxiety Disorder (GAD) 7 score was 21. The requested TMS is medically necessary.