TMS denials in California external review
In the California DMHC record, independent physician reviewers decided 346 published external-review cases involving TMSand overturned the plan’s denial in 56.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Major Depressive Disorder | 199 | 58.3% |
| Depression | 31 | 35.5% |
| Treatment-resistant Depression | 23 | 78.3% |
| Major Depression | 17 | 52.9% |
| Bipolar Disorder | 15 | 6.7% |
| Treatment-resistant Major Depressive Disorder | 13 | 92.3% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 188 | 66% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 157 | 44.6% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for therapy once a week (with the same therapist), Transcranial Magnetic Stimulation (TMS), and coping classes. Findings: The physician reviewer found that American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.
A 62-year-old female requested coverage for transcranial magnetic stimulation services from a specific date and onward. Findings: Two physician reviewers found that the patient is has an approximate 20-year history of mood symptomatologies which have been worsening over the past two years; her psychiatric diagnosis is major depressive disorder. The symptom complex consists of depressed mood with negative schemas, poor motivation, apathy, decreased energy, social isolation, anhedonia, impaired concentration with distractibility, and sleep problems. The patient has been active in cognitive therapy for two years. There are no reports of treatment with electroconvulsive therapy or in a setting other than the outpatient setting.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation. Findings: The physician reviewer found that Transcranial magnetic stimulation is a non-invasive intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population for those have failed at least one antidepressant medication trial. Transcranial magnetic stimulation is not indicated at this time for other psychiatric conditions, such as bipolar illness, anxiety disorders or trauma-related disorders, and the data are mixed on its applicability for chronic depressiveness.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for transcranial magnetic stimulation (TMS) (36 sessions). While TMS is efficacious and well tolerated in adults with major depressive disorder (MDD), the potential utility of TMS in adolescents with treatment-resistant depression is based on case reports and unblinded studies with a relatively small sample size of patients. Researchers found that while preliminary data suggest that repetitive TMS (rTMS) may be efficacious for pediatric depression, randomized controlled trials that examine both short and long-term outcomes are needed before definitively recommending rTMS for adolescents with refractory depression.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
Compare residential, PHP, IOP, inpatient, and withdrawal-management disputes without mixing TMS into the facility-intensity denominator: behavioral-health level-of-care evidence guide.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving TMS, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY