Treatment-resistant Major Depressive Disorder: when insurers say no, reviewers often say yes

Where the denial was 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 enrollee’s 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 enrollee’s 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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for esketamine (Spravato) nasal spray. This patient carries a documented diagnosis of major depressive disorder, recurrent severe, without psychosis. Moreover, the patient meets the definition of treatment resistant major depressive disorder due to failure of medical therapies including high-dose Paxil 40 mg and Lexapro. He has also had multiple trials of sufficient duration with Wellbutrin. Currently, he is on Viibryd 40 mg daily in addition to Wellbutrin XL 300 mg daily and BuSpar 5 mg three times a day. He is currently on the maximum dose of Viibryd, and has undergone a sufficient trial of medication and Wellbutrin.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement for transcranial magnetic stimulation (TMS). The enrollee has anxiety, recurrent severe major depressive disorder (MDD), severe obsessive compulsive disorder (OCD), and panic disorder. The enrollee reported social interactions and school can be very stressful; life in general is always worrisome and his mind does not stop worrying. His psychiatrist performed a transcranial magnetic stimulation (TMS) evaluation and recommended TMS per protocol for MDD with obsessional features. The enrollee has been struggling with severe depression and has utilized antidepressants unsuccessfully in the past. Use of repetitive TMS for treatment of resistant or refractory depression is consistent with treatment guidelines from a professional society.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for treatment-resistant major depressive disorder was denied, the published record says the denial is worth fighting.