What WorkSafe will pay for
The WorkSafe Agent (the Agent) can pay the reasonable costs of repetitive Transcranial Magnetic Stimulation (rTMS) when required for treating resistant depression 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.
What is rTMS?
rTMS is a mild form of brain stimulation. Magnetic fields, generated by a simple coil placed on the head, are used to stimulate a small area of the brain. The stimulation takes 20-45 minutes and is typically given over consecutive weekdays. Both acute and maintenance rTMS treatment courses are considered a block of up to 30 rTMS treatments. While receiving stimulation, the patient is fully awake. rTMS is usually well tolerated with minimal side effects. There is no anaesthetic and memory is not affected.
rTMS can be offered as a treatment for depression when patients have not responded to two or more antidepressant medications (usually from two or more different classes) or cannot tolerate antidepressant medications due to side effects. It is important that a thorough psychiatric evaluation, involving a specialist psychiatrist, is undertaken for each patient to determine if rTMS is a suitable treatment.
What can the Agent pay for in relation to rTMS?
rTMS is considered a non-established, new or emerging treatment (NeNET) because there is no Medicare Benefits Schedule (MBS) item number. It is payable under this policy if there are exceptional circumstances and it is deemed a suitable treatment by the treating psychiatrist.
The Agent can therefore pay the reasonable cost of rTMS where:
- rTMS occurs as an outpatient
- the patient has a diagnosis of a depressive disorder and the patient has not responded to, or been unable to tolerate, adequate trials of at least two antidepressant medications or cannot tolerate antidepressant medications due to side effects
- it is safe, effective and clinically justified
- an initial consult for acute rTMS course includes:
- a comprehensive assessment, which involves consultation with an appropriately trained psychiatrist
- the psychiatrist determining if the patient is eligible for rTMS treatment
- an appropriately trained psychiatrist, registered nurse or allied health professional conducting the mapping procedure in consultation with an appropriately trained rTMS psychiatrist
- pre and post reporting on outcome measures provided to the referring treating psychiatrist and the WorkSafe Agent
If the dot points are all satisfied, the Agent can pay the treatment and maintenance fees for the rTMS delivery.
In circumstances where a psychiatrist is clinically required as part of rTMS treatment, please refer to the Medical Practitioner policy.
Who can request rTMS?
A treating psychiatrist.
Who can prescribe rTMS?
An appropriately trained psychiatrist.
Who can deliver rTMS?
rTMS can only be provided by WorkSafe registered providers and delivered by a trained mental health professional (eg psychiatrist, psychologist or registered nurse), under supervision of a rTMS credentialed psychiatrist.
Where is rTMS undertaken?
rTMS take place in a psychiatric clinical setting with appropriate protocols, training, equipment and medical assistance available.
It is an outpatient treatment (unless otherwise approved by the Agent and included as part of the inpatient stay ; please refer to the Private Hospitals policy).
rTMS treatment centres should be appropriately accredited though a relevant standards agency such as the International Standards Organisation (ISO) or the Australian Council on Healthcare Standards (ACHS).
Criteria required when accessing inpatient rTMS
Provision of rTMS treatment alone is not sufficient indication for an inpatient admission. The patient can access inpatient rTMS services only if the treating psychiatrist has undertaken a comprehensive mental health assessment and the level of distress, risks and/or disability is assessed as acute, severe, or serious.
This can be evidenced by, but not confined to:
- high risk of harm to self or others
- incapacitating symptoms or distress (this may be evidenced by 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 specifically unsuitable
- a clearly documented care plan
In relation to rTMS what will the Agent not pay for?
The Agent will not pay for:
- 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
- services that are of no clear benefit to the worker
- non-attendance fees where a worker failed to attend
- the cost of telephone calls and telephone consultations between providers and workers, and between other providers, including hospitals
- treatment/services subcontracted to a non-registered provider
- services provided outside of Australia without prior approval from the Agent
- treatment provided to members of the immediate family by the medical practitioner
- invoices that do not meet WorkSafe's invoicing guidelines for medical practitioners rTMS treatment in conjunction with Electroconvulsive Therapy (ECT)
- rTMS services provided to an injured worker during an inpatient admission. If rTMS is separately approved to apply as part of an inpatient admission it is considered to be included in the bed fee as an inpatient and cannot be billed in addition to the bed fee