Repetitive transcranial magnetic stimulation policy

What WorkSafe will pay for

The WorkSafe Agent (the Agent) can pay the reasonable costs of repetitive Transcranial Magnetic Stimulation (rTMS) for treatment-resistant depression (TRD) caused by a work-related injury or illness under Victorian workers compensation legislation.

The Agent will review a worker's entitlement to rTMS at each request to ensure the treatment and services remain reasonable for the work-related injury or illness and are payable under the legislation. Prior approval from the Agent is required for rTMS treatment.

This policy must be read in conjunction with the following documents:

Definitions

What is rTMS?

rTMS is a form of brain stimulation. Magnetic fields, generated by a coil placed on the head, are used to stimulate a small area of the brain. rTMS is usually well tolerated with minimal side effects. There is no anaesthetic and no memory loss as a result of treatment. The stimulation takes 20-45 minutes and is typically given over consecutive weekdays. An acute rTMS treatment course is usually comprised as a block of up to 20 - 35 rTMS treatments in a period of 4 – 7 weeks. Maintenance rTMS treatment is administered after receiving acute treatment to prevent relapse. While evidence of maintenance rTMS is still evolving, tapered and clustered approaches are deemed suitable.

What is TRD?

Treatment-resistant depression (TRD) is the term given to persistent major depressive disorder (MDD) in spite of failed attempts of pharmacotherapy (antidepressant medication). rTMS can be offered as a viable option for TRD when patients have not responded to two or more different classes of antidepressant medications or cannot tolerate antidepressant medications due to side effects. It is important that a psychiatric evaluation, involving a specialist psychiatrist, is undertaken to determine if rTMS is a suitable course of action, taking into consideration any concurrent treatments and the worker's medical history.

Guidelines

What can the Agent pay for?

The Agent can pay the reasonable cost of rTMS treatment as per the WorkSafe rTMS Fee Schedule where:

• rTMS occurs as an outpatient treatment
• the Agent has received a request for treatment, and subsequently granted prior approval
• the injured worker has a diagnosis of major depressive disorder (MDD) and has not responded to, or has been unable to tolerate (due to side effects), adequate trials of at least two different classes of antidepressant medications
• when clinically indicated, the injured worker has previously trialled psychological therapy
• the injured worker is an adult, aged 18 years or older
• the rationale is safe, effective and clinically justified

Who can request rTMS?

Only a treating psychiatrist can request rTMS. All other treating health professionals must first refer to a qualified psychiatrist for review.

Who can prescribe rTMS?

An rTMS-trained treating psychiatrist employed at a WorkSafe-registered rTMS provider.

Who can administer rTMS?

rTMS can only be provided by WorkSafe registered providers and administered by:

• the rTMS-trained treating psychiatrist, and/or
• a healthcare professional on behalf of a psychiatrist, who has undertaken rTMS training

Where is rTMS undertaken?

rTMS treatment is provided in WorkSafe-approved psychiatric clinical settings with appropriate protocols, training, equipment and medical assistance. rTMS is delivered as an outpatient treatment unless otherwise approved by the Agent; please refer to the Private Hospitals Policy and required criteria as specified below. As per WorkSafe registration criteria, authorised rTMS providers are expected to maintain accreditation under a relevant quality standards agency such as the International Standards Organisation (ISO) or the Australian Council on Healthcare Standards (ACHS).

What constitutes an initial assessment for rTMS treatment?

An initial assessment for an rTMS course includes:

• a comprehensive review of the injured worker, including consultation with an rTMS accredited psychiatrist, determining if rTMS is an appropriate treatment for the worker
• an rTMS accredited psychiatrist; or psychiatry trainee or registered nurse in consultation with an rTMS accredited psychiatrist, conducting the mapping procedure
• baseline (and any prior) outcome measures provided to the referring treating psychiatrist and the WorkSafe Agent (the Hamilton Depression Scale is recommended for the determination of response and remission as treatment progresses)

The initial assessment is only paid once per acute (TMS001) or maintenance (TMS004) course as per the WorkSafe rTMS fee schedule.

What constitutes acute rTMS treatment?

Acute rTMS treatment may be approved under the following criteria:

• Approval for eligible workers can be granted for up to 35 treatment sessions by the Agent, in consultation with the Medical Advisor. It is expected that the treating rTMS accredited psychiatrist undertake outcome measurements (such as the Hamilton Depression Scale) at baseline (initial assessment), mid-treatment (approximately session 20) and upon completion of the rTMS course.
• If more than 35 acute treatments are required then additional approval from Clinical Panel psychiatrists is required.
• If a worker experiences relapse and another course of acute rTMS treatment is prescribed, then additional approval from Clinical Panel psychiatrists is required.
• A minimum of 4 months must have elapsed since the cessation of any prior acute or maintenance treatment, allowing sufficient time for full treatment effectiveness to be assessed.

What constitutes maintenance rTMS treatment?

Maintenance rTMS treatment may be approved under the following criteria:

• Approval for eligible workers may be granted for up to 15 treatment sessions by the Agent, in consultation with the Medical Advisor.
• If more than 15 maintenance treatments are required then additional approval from Clinical Panel psychiatrists would be required.
• A minimum of 4 months must have elapsed since the end of any prior acute or maintenance treatment, allowing for latent effects.

Psychiatry reviews during treatment

It is expected that the treating psychiatrist will engage in regular review of the patient including an initial assessment, review at or before session 20 (for acute courses) and upon completion of the prescribed course. Please refer to the Medical Practitioner policy and Medical fee schedule for information on psychiatry consultations.

What will the Agent not pay for?

The Agent will not pay for:

• more than one initial assessment per acute or maintenance treatment course
• outpatient rTMS treatments that occurred during an inpatient hospital stay
  • If rTMS is separately approved to apply as part of an inpatient admission, then it is considered to be included in the bed fee as an inpatient and cannot be billed in addition to the bed fee (see required criteria for inpatient rTMS).
• services for a condition that existed before the work-related injury or illness or that is not a direct result of the work-related injury or illness
• non-attendance fees where a worker failed to attend
• treatment/services provided by or subcontracted to a non-registered provider
• services provided outside of Australia
• treatment provided by members of the immediate family
• invoices that do not meet WorkSafe's invoicing guidelines for providers
• rTMS treatment in conjunction with Electroconvulsive Therapy (ECT)

Criteria required for accessing inpatient rTMS

WorkSafe Victoria strongly encourages the delivery of rTMS treatment in an outpatient setting. Provision of rTMS treatment alone is not a sufficient indication for an inpatient admission. An inpatient rTMS treatment is only accessible if the treating psychiatrist has undertaken a comprehensive mental health assessment and the level of distress, risks and/or disability is assessed as acute or severe. Inpatient rTMS will only be considered by means of a NeNETS request and Clinical Panel psychiatrist review.

This can be evidenced by, but not confined to:

• an assessment of high risk of harm to self or others
• incapacitating symptoms or distress (e.g. a highly disorganised state impacting on self–care and/or physical health, including inability to comply with treatment, resulting in a need for 24 hour care)
• significant problems in initiating treatment, or continuing treatment, in another setting

What are reasonable supports for an inpatient stay while receiving rTMS?

Reasonable supports include:

• rTMS therapy on a daily basis at least five days per week.
• regular medical/psychiatric reviews: at least two times per week
• therapeutic group programs unless this is deemed unsuitable
• a clearly documented care plan