Diagnosis: Depression.
Treatment: Transcranial Magnetic Stimulation (TMS).

The insurer denied transcranial magnetic stimulation (TMS). The health plan's determination is upheld.

The patient is a male with diagnosis of major depressive disorder, recurrent moderate whose provider is requesting treatment with transcranial magnetic stimulation (TMS). The progress indicates the patient is interested in TMS for depression and possibly co-existing pain. He reported some stress at work. The patient's affect was noted to be a broad range and appropriate and his mood was dysthymic but less angry and mildly anxious. The plan was to continue the patient's current medications and to refer him for TMS.

Transcranial magnetic stimulation (TMS) is not likely to be more beneficial than any standard treatment for the insured's life-threatening or disabling condition or disease. The documentation provided is not consistent with a diagnosis of treatment-resistant depression, which is generally defined as a failure of at least two different antidepressants medications of the same or different classes, administered at adequate doses and for an adequate amount of time which fails to produce significant clinical results. The documentation indicates the patient has taken his current medication regimen since last year. While his dose of escitalopram is maximized, his dose of Zyprexa is 5 milligrams (mg), and the maximum recommended daily dose for treatment of major depressive disorder is 20mg. As such, he has not failed treatment with at least two antidepressant medications and cannot be considered treatment-resistant.
Additionally, a review of the medical literature concludes that augmentation with TMS is not significantly better than standard pharmacological augmentation therapies in the treatment of treatment-resistant depression.