CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Electroconvulsive Therapy (ECT) Prior Authorization Request

This document is a prior authorization request form and guidance for requesting ECT services for Blue Cross Blue Shield members; it is used by providers/facilities to obtain authorization for initial or continuation ECT (inpatient or outpatient).

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyElectroconvulsive Therapy (ECT) Prior Authorization Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization electronically via Availity or by fax to 844-430-1702 with required clinical and administrative information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5form pages indicated

844-430-1702fax number

Availityelectronic site

800-499-9554PHI contact

Coverage and Medical Necessity Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

These documents contain Protected Health Information (PHI). Federal and state laws prohibit inappropriate use or disclosure of PHI. If you are not the intended recipient or the person responsible for delivering these documents, you must properly dispose of them. Providers must return, destroy, or otherwise protect any PHI received that pertains to patients they are not treating. Providers are required to immediately destroy such PHI or to safeguard it for as long as it is retained; in no event may the PHI be used or re‑disclosed. For instructions on PHI handling or disposal, call 800-499-9554.

Authorization signifies that MCG medical necessity guidelines have been met for the requested service(s); however, authorization does not guarantee payment. Payment remains contingent on member eligibility and benefit limitations at the time services are rendered. The form is used to document clinical information that supports a medical necessity determination but does not itself override benefit or eligibility rules.

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization Required

Submit prior authorization requests electronically via Availity (https://www.availity.com) or fax to 844-430-1702. Use the Electroconvulsive Therapy (ECT) Prior Authorization Request form to provide complete clinical and administrative details for review.

Availity submission or fax: 844-430-1702
Use the ECT Prior Authorization Request form

Denial Risk

Authorization Is Not a Payment Guarantee

Authorization indicates that MCG medical necessity guidelines have been met for the requested service(s) but does not guarantee payment. Payment is contingent upon member eligibility and benefit limitations at the time services are rendered.

Documentation Required

Required Submission Information

Include complete member, provider and treatment information on the request form. Incomplete submissions may delay review.

Member details: name, member number, date of birth, address
Provider/facility details: facility name, facility NPI, facility TIN, attending provider name and NPI, UM rep contact, phone and fax
Treatment stage and location: initial ECT series vs continuation; inpatient vs outpatient
Number of treatments and dates of service
Medical clearance and second opinion documentation (inpatient/outpatient)
Current risk factors and mental status exam
Treatment team and history of inpatient treatment, compliance, and social support
Recent ECT treatment record (for continuation requests): dates, provider, pretreatment scores, unilateral/bilateral, seizure duration, response, provider signature

Step Therapy

Medication and Step-History Documentation

Provide a detailed medication and step-therapy history, including current medications, past medication trials, doses, durations, responses, and any adverse effects or poor response to adequate antidepressant trials.

Current medications list (include behavioral and physical health meds or medication administration record)
History of medications tried and results (dose, duration, response)
Documentation whether patient had poor response to several adequate antidepressant trials
Details if patient had a good prior response to ECT or adverse effects to medications

Background

Electroconvulsive therapy (ECT) may be requested either as an initial series or as continuation treatment, and can be provided in either an inpatient or outpatient setting. The prior authorization form collects clinical details to support medical clearance and necessity review, including current risk factors, medical clearance documentation, treatment history, current medications, and—for continuation requests—a recent ECT treatment record with pretreatment score, electrode placement (unilateral/bilateral), seizure duration, clinical response, and provider signature.

Key Definitions

Stage of treatment

DefinitionIndicates whether the request is for an initial ECT series or for continuation of previously started ECT treatment.

Form fieldCheckboxes labeled 'Initial ECT series' and 'Continuation of treatment' appear under 'Stage of treatment' on the provider information section.

Required on submissionProviders must indicate stage of treatment on the prior authorization form to support medical necessity review and appropriate review pathway.

Location of treatment

DefinitionSpecifies whether ECT will be performed in an inpatient setting or an outpatient setting.

Form fieldCheckboxes labeled 'Inpatient ECT' and 'Outpatient ECT' appear under 'Location of treatment' in provider information and under 'Medical clearance for ECT treatment'.

Documentation purposeLocation selection helps determine level-of-care criteria and whether inpatient medical clearance is indicated on the form.

ECT Treatment Modalities

ECT

ECT treatment modalities: Form captures unilateral vs bilateral electrode placement and seizure duration as part of recent treatment record; medication history and response to prior antidepressant trials and prior ECT response are documented to support necessity.

Information used for initial and continuation treatment reviews; recent ECT treatment record required for continuation requests.