Repetitive Transcranial Magnetic Stimulation denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with major depressive disorder. The patient reported feeling as if her depression was in remission. The patient was noted to have begun transcranial magnetic stimulation (TMS) treatment for maintenance in January 2020 after completing acute phase treatment. In a letter, the provider noted that the patient received TMS treatments in 2017 with a remarkable change in the patient’s condition, although the improvement was not sustained. The provider noted that the patient had rapid decompensation and was treated with additional TMS treatments 2018 and 2019. Per the records, the Patient Health Questionnaire (PHQ-9) scores were noted to have increased from zero in February 2020 to 10 in April 2020.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the (1) telephone evaluation (CPT 99442) provided by Sheldon Jordan, M.D., (2) office visit (CPT 99214) provided by Sheldon Jordan, M.D., (3) advanced magnetic resonance imaging (MRI) (CPT 76498) provided by Sheldon Jordan, M.D., and (4) all or any of the repetitive transcranial magnetic stimulation (rTMS) (CPT 90868) received from Sheldon Jordan, M.D. Current medical literature supports the use of rTMS in the treatment of patients with fibromyalgia. Yang and Chang note that the results of a systematic narrative review suggest that TMS is beneficial for treating neuropathic pain of various origins, including from fibromyalgia. Lefaucheur and colleagues report that evidence suggest probable efficacy in the use of rTMS in improving the quality of life and decreasing pain in patients with fibromyalgia.

Where the denial was upheld

A 39-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder. Findings: Two physician reviewers found that according to peer-reviewed literature on the topic of antidepressant treatment, there are varying reports on the efficacy, especially long-term, and potential side effect profile and case selection for benefit of repetitive transcranial magnetic stimulation (rTMS). Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. The authors reported that although results are suggestive that rTMS has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for repetitive transcranial magnetic stimulation (TMS) for treatment of the enrollee’s depression. Findings: The physician reviewer found that although some preliminary positivism regarding the application of TMS therapy for the bipolar population can be found in the medical literature, the absence of well-controlled and adequately powered exploratory and confirmatory studies do not establish TMS as a treatment of bipolarity. Further, this patient’s records do not include a current psychiatric evaluation, progress notes or discharge summaries from the recent hospitalization and aftercare programming. Given the lack of documentation, the records do not support a diagnosis of bipolar disorder or major depressive disorder.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Repetitive Transcranial Magnetic Stimulationwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.