TMS for Mental Disorder: 56.7% of denials overturned
In 314 California IMR decisions from 2010 to 2025, reviewers overturned 178 (56.7%). In the last five years: 80.0% of 50. 168 were medical-necessity disputes, 145 experimental/investigational, 1 urgent care.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 12 | 66.7% |
| 2022 | 13 | 84.6% |
| 2023 | 8 | 62.5% |
| 2024 | 9 | 100.0% |
| 2025 | 8 | 87.5% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 179 | 60.3% | 56.7% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 71 | 66.2% | 56.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 45 | 2.2% | 56.7% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 25 | 76.0% | 56.7% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 24 | 33.3% | 56.7% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 15 | 46.7% | 56.7% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 8 | 62.5% | 56.7% |
| Step therapy or fail-firstThe findings mention a fail-first requirement. | 4 | 25.0% | 56.7% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for 20 sessions of transcranial magnetic stimulation services. Per the medical records, the patient has major depressive disorder and has failed psychotherapy and multiple antidepressant medications and augmentation agents. In this patient’s case, 20 sessions of transcranial magnetic stimulation services are in accordance …”
“The physician reviewer found that a patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) treatment. In this case, the record establishes that the patient has been diagnosed with treatment-resistant depression, which has been occurring for a significant duration of the patient’s life. In addition, the patient has a history of substance abuse, suicidal ideation (SI), and multiple …”
“The physician reviewer found that a patient has requested reimbursement for transcranial magnetic stimulation (TMS) treatment. In this case, the record establishes that the patient has treatment-resistant depression (TRD). Further, the patient has failed to respond to at least two adequate pharmacologic trials and psychotherapy. The consensus in the medical literature and clinical guidelines supports TMS as a medically appropriate …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. In this case, the patient's medical records indicate a history of treatment-resistant depression with multiple failed medication trials and augmentation strategies. The patient has engaged in extensive psychotherapy and has previously benefited from TMS. However, the records lack detailed documentation of the …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were TMS denials for Mental Disorder overturned?
In 314 California IMR decisions from 2010 to 2025, reviewers overturned 178 (56.7%). In the last five years: 80.0% of 50. 168 were medical-necessity disputes, 145 experimental/investigational, 1 urgent care.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.