What if a left-handed patient goes for a full course of TMS treatment covered by insurance where the doctor used high frequency stimulation to the left DLFPC but the patient doesn’t respond positively. Then the patient goes to a new doctor, pays out of pocket, that new doctor is willing to try a different protocol such as high frequency to the right DLPFC for a couple sessions and the patient responds positively. Is insurance likely to approve further treatment using the changed protocol since the patient has shown a positive response during those out of pocket sessions? If so, is there a certain level of response required?
It will be denied automatically but the doctor can take it to "peer to peer". If this is United Healthcare (Optum) or Aetna, most likely will be denied. If this BCBS or Cigna, then there might be a chance for approval. Either way, the patent will have an option to appeal. Insurances do listen to patients.
What if a left-handed patient goes for a full course of TMS treatment covered by insurance where the doctor used high frequency stimulation to the left DLFPC but the patient doesn’t respond positively. Then the patient goes to a new doctor, pays out of pocket, that new doctor is willing to try a different protocol such as high frequency to the right DLPFC for a couple sessions and the patient responds positively. Is insurance likely to approve further treatment using the changed protocol since the patient has shown a positive response during those out of pocket sessions? If so, is there a certain level of response required?
It will be denied automatically but the doctor can take it to "peer to peer". If this is United Healthcare (Optum) or Aetna, most likely will be denied. If this BCBS or Cigna, then there might be a chance for approval. Either way, the patent will have an option to appeal. Insurances do listen to patients.
Can you point us toward the clinical research that supports extending treatment beyond 30 sessions for late responding patients? Thank you.
Here is the one for F8 coil extension of treatment pubmed.ncbi.nlm.nih.gov/18294022/
Here is the one for H1 coil pubmed.ncbi.nlm.nih.gov/28330592/