LCD Reference Article Response To Comments Article

Response to Comments: Repetitive Transcranial Magnetic Stimulation for Major Depressive Disorder

A55902

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Source Article ID
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Article ID
A55902
Original ICD-9 Article ID
Not Applicable
Article Title
Response to Comments: Repetitive Transcranial Magnetic Stimulation for Major Depressive Disorder
Article Type
Response to Comments
Original Effective Date
05/14/2018
Revision Effective Date
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Article Text

Noridian's Response to Provider Recommendations for Repetitive Transcranial Magnetic Stimulation for Major Depressive Disorder (for comment period ending 04/10/2017)

 

 

Response To Comments

Number Comment Response
1

There were several comments relating to pricing of this service as it is currently Contractor priced.

Pricing is not within the purview of the CAC process.

2

There were several comments relating to the requirement that repetitive transcranial magnetic stimulation be ordered and performed by the psychiatrist who ordered the service.

Noridian has altered the requirements for this to be somewhat consistent with the guidelines of the TMS Society.  Since the treating psychiatrist is no longer required to personally administer the rTMS, other training requirements of all involved in treatment were added to the policy, consistent with the guidelines of the TMS Society

3

There were a few comments requesting the removal of the requirement for psychotherapy prior to the initiation of repetitive transcranial magnetic stimulation or to decrease the number of required weeks of psychotherapy prior to initiation of rTMS

Psychotherapy is a proven therapy for treatment resistant depression.  Evidence regarding repetitive transcranial magnetic stimulation, the appropriate length of its first course, the use of repetitive courses and its long-term durability is still under study.  The Contractor would not drop a requirement for a proven known treatment in favor of one in which the evidence is still evolving.  The length of the psychotherapy trial is no longer specified.

4

One commenter requested that initial treatment be extended to forty-four sessions.

No peer reviewed published articles were submitted to support this position and there were no other comments in this regard.   The Contractor declines to change the language of the policy.  However, cases that require more treatment than the average may be appealed for consideration with documentation.

5

A few commenters objected to the limitation of motor threshold re-determination to once per patient for rTMS overall.  A society pointed out that more than one could be needed if a change in cortical excitability might be likely to occur and suggested that the Contractor establish a reasonable limit within a certain time frame.

The limitation of one service per patient per overall use of rTMS has been removed.  Noridian has increased this limit to three in a rolling six-month period.  Claims beyond that number will be denied.  They may be appealed for review with the appropriate documentation as described in the policy.

6

Several objections were raised regarding the limit of two treatments of rTMS for a patient. 

Any reference to a two-treatment limit has been removed from the policy.  However, documentation supporting the need for a retreatment must be clear and distinguishable from maintenance therapy.

7

There were isolated comments regarding special situations such as the use of this technology in patients with relative contraindications such as seizures, cerebral infarcts, the presence of other devices, mild dementia etc.

Only one article citing two cases of treatment with rTMS in patients with left frontal stroke was submitted in support of this position.  At this time, such cases will be denied.  Documentation supporting the medical necessity and rationale of rTMS in these patients may be submitted for consideration through the appeals mechanism.

8

There were several comments objecting to the use of scoring mechanisms for initiation and follow up of rTMS services.  Clinical trials do not necessarily reflect what is happening in the real world.

Noridian recognizes the point made by the commenters.   However, literature is still evolving in relation to this service.  The Contractor relies on the prescribing psychiatrist to confirm not only the diagnosis of severe treatment resistant depression but the medical necessity of the treatment with rTMS.  Frequently, progress notes submitted to Noridian have little rationale or substance to support medical necessity for services, in general.  The Contractor will, therefore, keep the current requirements.  We expect these studies to be performed at the baseline for initiation of rTMS and subsequently as the policy describes.  The appeals mechanism is available for cases in which the referring practitioner has not utilized scoring mechanisms in treatment but in which the psychiatrist ordering rTMS strongly feels the treatment would be medically necessary.

9

There were a few comments requesting coverage of patients where scoring mechanisms might indicate the depression was moderate but functionality was as poor or worse than the functionality of the treatment resistant patient with a major depressive disorder.

At the current time, Noridian feels these situations would best be handled through the appeals mechanism with supporting documentation for the rationale to treat in this manner.

10

One comment was received requesting the expansion of coverage to whatever this device is being used for in the community

This policy was specifically limited to the use of this therapy in the treatment of major depressive disorder.  No peer reviewed literature was submitted.  Noridian specifically will deny coverage for all other uses of this device, as noted in the policy.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L37086 - Transcranial Magnetic Stimulation (TMS)
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
03/14/2018 05/14/2018 - N/A Currently in Effect You are here

Keywords

  • •rTMS
  • •TMS
  • •90867
  • •90868
  • •90869
  • •Transcranial Magnetic Stimulation
  • •Depressive Disorder