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United Healthcare Transcranial Magnetic Stimulation Therapy Coverage Policy

Age 18 years or older

The member has severe major depressive disorder (single or recurrent episode)

Failure of a trial of psychotherapy

Inadequate response to 4 antidepressants and augmentation therapy

One of the following scenarios applies:

Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically significant response to four trials of psychopharmacologic agents in the current depressive episode from at least two different agent classes. The individual’s medication dose during the failed trials should have been above the minimal effective dose and duration in the current episode.

Inability to tolerate psychopharmacologic agents as evidenced by four trials of psychopharmacologic agents from at least two different agent classes, with distinct side effects. Psychopharmacologic agent side effects will be considered intolerable, when those side effects are of a nature where they are not expected to diminish or resolve with continued administration of the drug.

The individual has a documented history of response to transcranial magnetic stimulation (TMS) in a previous depressive episode, as evidenced by a greater than 50% improvement on a standardized rating scale for depression symptoms.

If the individual is currently receiving electro-convulsive therapy, rTMS may be considered reasonable and necessary as a less invasive treatment option.

A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration has been attempted without significant improvement in depressive symptoms as documented on a standardized rating scale for depression symptoms.

The individual’s current baseline depression measurement score has been documented using an evidence-based validated rating scale (e.g., BDI; HAM-D; MADRS).

TMS treatment is provided using a device that is approved by the U.S. Food and Drug Administration (FDA) for the treatment of major depressive disorder.

TMS treatment is prescribed by a psychiatrist trained in the use of the specific device. The procedure is provided by or is under the direct supervision of a psychiatrist trained in the use of the specific device The TMS operator should be trained and certified to deliver repetitive transcranial magnetic stimulation (rTMS) including device operation, TMS coil targeting, and recognition and management of side effects. He or she should be trained as a first responder to a seizure and have basic life support training.