General prior authorization guidelines
There are four items in any prior auth request:
1. Establish the diagnosis.
2. Document all medication trials.
3. Document prior psychotherapy.
4. Document having tried or considered ECT or its contraindications.
First, it is still vital and recommended that ALL patients having insurance coverage sign an Advanced Beneficiary Notice (ABN) form. Without this, you cannot go to appeals with some carriers. In addition, if they order you to refund a patient for TMS because of improper ABN procedures, contracted providers must comply and issue the refund. Medicare is especially tough on this issue, so be sure you use the 2011 ABN form for Medicare patients. You must prove that the patient clearly understood that TMS was known to be a non-covered service prior to starting, so be sure they sign the ABN at least one day prior to starting TMS therapy, and be sure to document all signatures, and that the patient received a copy of the fully executed ABN. Do not leave ANY blanks on the ABN forms.
Next, be sure your initial TMS evaluation is comprehensive and meets documentation criteria for a level 5 consultation (the former CPT code 99245). It must include a full history of the CURRENT depressive episode, and an overview history of any prior episodes, as well as a complete mental status exam and 5-axis diagnosis. This is the medical documentation on which you will base both prior auth requests AND appeals. Since you are asking for up to $15,000 of insurance payments, the evaluation needs to be the most complete you have ever produced. If you have support staff work on documentation, be sure you add as much clinical history of the current illness, as well as deficits in functioning, and outline the debility the depression is causing the patient, before you lock the note.
Obtain appropriate releases from the patient, and then send for the local pharmacy records going back at least two years, as well as treatment records from prior psychiatrists and other physicians within the current episode. Your staff should help expedite these requests, if the need for TMS is urgent, since routine requests can take weeks. Recruit the patient and the family to help obtain the treatment history (i.e. go to the pharmacy or office and physically bring you the records). Patients are notoriously unreliable in giving exact dates, doses and results of prior medication trials, so you will need this information for your auth request.
With your note complete, compose a Letter of Medical Necessity (LOMN). Regardless of whether the insurance has a policy regarding TMS payment, your LOMN requires the following four elements:
LOMN element 1
Outline, in great detail, the current depressive episode, including each of the DSM symptoms, onset, duration, and degree of functional limitation caused by the depression. You must clearly prove the patient has a major depressive episode "by the book." You can copy and quote from your comprehensive evaluation. I usually include patient quotes, which are repeated from the evaluation made by the patient. Good examples include, "I had to drop out of school this term because I couldn’t think straight and function.”, or "this is the most severe episode I ever had, and my husband has to take care of the house and the kids because I'm so depressed now."
IMPORTANT: Do not make any claim in the LOMN that you cannot support in your comprehensive evaluation or from the medical records obtained from prior treating clinicians. Resist any temptation to embellish the LOMN. The insurance companies will dissect both your letter and evaluation and any inconsistencies or unsupported facts could not only jeopardize your prior auth request, but also may tend to reduce your credibility with the insurance case managers.
If there are other diagnoses, such as bipolar disorder, eating disorders, schizoaffective disorder or substance abuse, be sure that you note in both the evaluation and the LOMN that these are either secondary or stable, with the focus of the LOMN on the depressive episode itself. While some insurance companies will authorize TMS for dysthymia or a depressive episode of bipolar or schizoaffective disorder, most go by the FDA indication and may reject a LOMN without a clean diagnosis of only Major Depressive Disorder (MDD).
LOMN element 2
List in order of most recent to most remote, EACH and EVERY trial of medications used in the current MDD episode. First, list the current medications, doses, durations and outcome. Then list trial 2, trial 3, trial 4, etc. We actually label and denote these trials. If you were trained by Neuronetics in the use of the prior treatment form, this is the same basis. Any change to the medication regimen counts as an ADDITIONAL trial. Insurance generally wants to see at least four separate trials, from at least two separate classes of antidepressant, with 1-2 augmentation strategies. Here is an example of a listing of med trials:
Current: Paxil CR 37.5 mg, Deplin 15 mg/d, Seroquel 100 mg/d started 12-1-2013. Depressive symptoms remain severe and Pt. is not responding to this combination of medication. The patient has also gained 10 lbs the past 2 months on Seroquel, so this cannot continue.
Trial #2: Paxil CR 37.5 mg, Deplin 15 mg/d, and Wellbutrin XL 300 mg/d. Wellbutrin was started 9-15-2013 and was used for 2.5 mos as augmentation. This helped energy, but did not improve depressive symptoms and wellbutrin was stopped 12-1-2013.
Trial #3: Paxil CR 37.5 mg/d and Deplin 15 mg/d, used from June 2013 to 9-15-13 as combination therapy and resulted in a slight improvement of symptoms, but then lost effect in September 2013.
Trial #4, etc. NOTE: If a patient tries a med for only a short time, that STILL COUNTS as a valid trial. You could note for example, "Cymbalta was tried as monotherapy for 10 days at 30 mg/d in January 2013, and was discontinued due to tachycardia. This is considered to be a treatment failure, tried and failed due to intolerance, since it could not be titrated to a therapeutic dose because of side effects."
LOMN Element 3
List any and all psychotherapy interventions in the current episode or in immediate past episodes. If there was none, then list ANY trial of psychotherapy, and specify if it was either Cognitive Behavioral Therapy (CBT) or InterPersonal (IP), since these are the criteria that most insurance companies use to approve LOMN's. Document the response to this psychotherapy, and be sure it matches the history in the available medical records or list as "per patient report" - as much information as you have. If the patient has never had psychotherapy, your LOMN will be very weak and may not be approvable by some companies. Recently I had one company tell me that the all of the criteria were met, except they wanted psychological test results from each follow-up visit and a course of psychotherapy. My patient promptly started CBT psychotherapy and I saw her every three weeks and we collected three sets of PHQ9 scores, and BDI scores (patient-rated scales). After about 10 weeks of this, her medications started to fail and we made a VERY complete progress note, and updated the LOMN to reflect the failure of CBT. We also included copies of the test scores. The insurance provider approved the TMS prior auth within one day. This was with a company with an established policy for TMS, but our good relationship with them and knowledge of their expectations guided us to provide and document the steps necessary to secure the authorization. If you are dealing with a company without a TMS payment policy in place, the prior auth process can take weeks or months. So, if your patient hasn't had a recent course of psychotherapy, get them started promptly, so if they shoot down the LOMN for lack of a trial of psychotherapy, you can update them with the progress to date with a quick appeal or maybe a phone call.
LOMN element 4. Mention whether ECT has been given in the past and that it has been at least considered in the current episode. It's ok to write a paragraph detailing the patient's fears about ECT regarding memory loss, anesthesia risks, and the disruption to occupational functioning or ADL's that would occur for the 4-5 week ECT course. Document whether the patient has access to a driver for each ECT treatment, and whether in your area the ECT trial would require hospitalization. You could point out the costs of hospitalization and ECT combined may be 2-3 times the cost of TMS to the insurance company. I usually contrast this in the same paragraph with the benefits of TMS over ECT, including no disruption to school or work schedules, no inpatient treatment, no memory loss, no driver necessary, no anesthesia risk, etc. If that patient has had ANY prior bad reaction to anesthesia, or ANY risk of nosocomial infection be SURE to put that in this section. I had one patient with a bad cardiac arrhythmia during a prior surgery, and another on meds for arthritis that suppressed her immune system, so therefore she should not be exposed to pathogens found in hospitals. Both of these patients got their TMS approvals within two days of the request. It seems that many insurance reviewers have ECT in mind and they contrast that with TMS, so if you can come up with even a relative contraindication (i.e. increased intracranial pressure, anesthesia risk) to ECT, even if it is a weak argument, it will help push the reviewers towards authorizing the TMS. The first level reviewers or case managers may simply need something to point them away from ECT and favor approving the TMS.
Finally, if there has been a prior trial of TMS therapy, be sure to list it as a prior treatment, even if it was in a previous episode, and especially if it was a good outcome, give the outline of treatment, # of treatments given, and a graph of the test scores so you can prove prior efficacy in this patient. That will go a long way towards getting authorization, and this information is valid even if that prior TMS treatment was paid in cash without any prior insurance reimbursement.
Concurrent with you and your staff writing the LOMN, you must obtain the instructions for submitting the LOMN. Fax (preferred) or mail the LOMN together with the comprehensive evaluation at the minimum. Other documents may be required.
Read more about these topics HERE
There are four items in any prior auth request:
1. Establish the diagnosis.
2. Document all medication trials.
3. Document prior psychotherapy.
4. Document having tried or considered ECT or its contraindications.
First, it is still vital and recommended that ALL patients having insurance coverage sign an Advanced Beneficiary Notice (ABN) form. Without this, you cannot go to appeals with some carriers. In addition, if they order you to refund a patient for TMS because of improper ABN procedures, contracted providers must comply and issue the refund. Medicare is especially tough on this issue, so be sure you use the 2011 ABN form for Medicare patients. You must prove that the patient clearly understood that TMS was known to be a non-covered service prior to starting, so be sure they sign the ABN at least one day prior to starting TMS therapy, and be sure to document all signatures, and that the patient received a copy of the fully executed ABN. Do not leave ANY blanks on the ABN forms.
Next, be sure your initial TMS evaluation is comprehensive and meets documentation criteria for a level 5 consultation (the former CPT code 99245). It must include a full history of the CURRENT depressive episode, and an overview history of any prior episodes, as well as a complete mental status exam and 5-axis diagnosis. This is the medical documentation on which you will base both prior auth requests AND appeals. Since you are asking for up to $15,000 of insurance payments, the evaluation needs to be the most complete you have ever produced. If you have support staff work on documentation, be sure you add as much clinical history of the current illness, as well as deficits in functioning, and outline the debility the depression is causing the patient, before you lock the note.
Obtain appropriate releases from the patient, and then send for the local pharmacy records going back at least two years, as well as treatment records from prior psychiatrists and other physicians within the current episode. Your staff should help expedite these requests, if the need for TMS is urgent, since routine requests can take weeks. Recruit the patient and the family to help obtain the treatment history (i.e. go to the pharmacy or office and physically bring you the records). Patients are notoriously unreliable in giving exact dates, doses and results of prior medication trials, so you will need this information for your auth request.
With your note complete, compose a Letter of Medical Necessity (LOMN). Regardless of whether the insurance has a policy regarding TMS payment, your LOMN requires the following four elements:
LOMN element 1
Outline, in great detail, the current depressive episode, including each of the DSM symptoms, onset, duration, and degree of functional limitation caused by the depression. You must clearly prove the patient has a major depressive episode "by the book." You can copy and quote from your comprehensive evaluation. I usually include patient quotes, which are repeated from the evaluation made by the patient. Good examples include, "I had to drop out of school this term because I couldn’t think straight and function.”, or "this is the most severe episode I ever had, and my husband has to take care of the house and the kids because I'm so depressed now."
IMPORTANT: Do not make any claim in the LOMN that you cannot support in your comprehensive evaluation or from the medical records obtained from prior treating clinicians. Resist any temptation to embellish the LOMN. The insurance companies will dissect both your letter and evaluation and any inconsistencies or unsupported facts could not only jeopardize your prior auth request, but also may tend to reduce your credibility with the insurance case managers.
If there are other diagnoses, such as bipolar disorder, eating disorders, schizoaffective disorder or substance abuse, be sure that you note in both the evaluation and the LOMN that these are either secondary or stable, with the focus of the LOMN on the depressive episode itself. While some insurance companies will authorize TMS for dysthymia or a depressive episode of bipolar or schizoaffective disorder, most go by the FDA indication and may reject a LOMN without a clean diagnosis of only Major Depressive Disorder (MDD).
LOMN element 2
List in order of most recent to most remote, EACH and EVERY trial of medications used in the current MDD episode. First, list the current medications, doses, durations and outcome. Then list trial 2, trial 3, trial 4, etc. We actually label and denote these trials. If you were trained by Neuronetics in the use of the prior treatment form, this is the same basis. Any change to the medication regimen counts as an ADDITIONAL trial. Insurance generally wants to see at least four separate trials, from at least two separate classes of antidepressant, with 1-2 augmentation strategies. Here is an example of a listing of med trials:
Current: Paxil CR 37.5 mg, Deplin 15 mg/d, Seroquel 100 mg/d started 12-1-2013. Depressive symptoms remain severe and Pt. is not responding to this combination of medication. The patient has also gained 10 lbs the past 2 months on Seroquel, so this cannot continue.
Trial #2: Paxil CR 37.5 mg, Deplin 15 mg/d, and Wellbutrin XL 300 mg/d. Wellbutrin was started 9-15-2013 and was used for 2.5 mos as augmentation. This helped energy, but did not improve depressive symptoms and wellbutrin was stopped 12-1-2013.
Trial #3: Paxil CR 37.5 mg/d and Deplin 15 mg/d, used from June 2013 to 9-15-13 as combination therapy and resulted in a slight improvement of symptoms, but then lost effect in September 2013.
Trial #4, etc. NOTE: If a patient tries a med for only a short time, that STILL COUNTS as a valid trial. You could note for example, "Cymbalta was tried as monotherapy for 10 days at 30 mg/d in January 2013, and was discontinued due to tachycardia. This is considered to be a treatment failure, tried and failed due to intolerance, since it could not be titrated to a therapeutic dose because of side effects."
LOMN Element 3
List any and all psychotherapy interventions in the current episode or in immediate past episodes. If there was none, then list ANY trial of psychotherapy, and specify if it was either Cognitive Behavioral Therapy (CBT) or InterPersonal (IP), since these are the criteria that most insurance companies use to approve LOMN's. Document the response to this psychotherapy, and be sure it matches the history in the available medical records or list as "per patient report" - as much information as you have. If the patient has never had psychotherapy, your LOMN will be very weak and may not be approvable by some companies. Recently I had one company tell me that the all of the criteria were met, except they wanted psychological test results from each follow-up visit and a course of psychotherapy. My patient promptly started CBT psychotherapy and I saw her every three weeks and we collected three sets of PHQ9 scores, and BDI scores (patient-rated scales). After about 10 weeks of this, her medications started to fail and we made a VERY complete progress note, and updated the LOMN to reflect the failure of CBT. We also included copies of the test scores. The insurance provider approved the TMS prior auth within one day. This was with a company with an established policy for TMS, but our good relationship with them and knowledge of their expectations guided us to provide and document the steps necessary to secure the authorization. If you are dealing with a company without a TMS payment policy in place, the prior auth process can take weeks or months. So, if your patient hasn't had a recent course of psychotherapy, get them started promptly, so if they shoot down the LOMN for lack of a trial of psychotherapy, you can update them with the progress to date with a quick appeal or maybe a phone call.
LOMN element 4. Mention whether ECT has been given in the past and that it has been at least considered in the current episode. It's ok to write a paragraph detailing the patient's fears about ECT regarding memory loss, anesthesia risks, and the disruption to occupational functioning or ADL's that would occur for the 4-5 week ECT course. Document whether the patient has access to a driver for each ECT treatment, and whether in your area the ECT trial would require hospitalization. You could point out the costs of hospitalization and ECT combined may be 2-3 times the cost of TMS to the insurance company. I usually contrast this in the same paragraph with the benefits of TMS over ECT, including no disruption to school or work schedules, no inpatient treatment, no memory loss, no driver necessary, no anesthesia risk, etc. If that patient has had ANY prior bad reaction to anesthesia, or ANY risk of nosocomial infection be SURE to put that in this section. I had one patient with a bad cardiac arrhythmia during a prior surgery, and another on meds for arthritis that suppressed her immune system, so therefore she should not be exposed to pathogens found in hospitals. Both of these patients got their TMS approvals within two days of the request. It seems that many insurance reviewers have ECT in mind and they contrast that with TMS, so if you can come up with even a relative contraindication (i.e. increased intracranial pressure, anesthesia risk) to ECT, even if it is a weak argument, it will help push the reviewers towards authorizing the TMS. The first level reviewers or case managers may simply need something to point them away from ECT and favor approving the TMS.
Finally, if there has been a prior trial of TMS therapy, be sure to list it as a prior treatment, even if it was in a previous episode, and especially if it was a good outcome, give the outline of treatment, # of treatments given, and a graph of the test scores so you can prove prior efficacy in this patient. That will go a long way towards getting authorization, and this information is valid even if that prior TMS treatment was paid in cash without any prior insurance reimbursement.
Concurrent with you and your staff writing the LOMN, you must obtain the instructions for submitting the LOMN. Fax (preferred) or mail the LOMN together with the comprehensive evaluation at the minimum. Other documents may be required.
Read more about these topics HERE
- Prior auth for insurance WITH a policy for approving TMS
- Prior auth for insurance WITHOUT a TMS approval policy
- Appealing denied authorizations or denied TMS claims
