Electroconvulsive Therapy (ECT) Initiation/Acute/Short-Term Request
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Forms and prior-authorization requirements for requesting initiation or short-term/acute courses of ECT for Bluecross Idaho members; applies to providers submitting authorization requests and facilities performing ECT.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Authorization criteria
Covered when the request includes complete documentation and meets medical necessity as determined by Blue Cross of Idaho.
Submission of the completed form by fax or phone does not constitute authorization of services. Blue Cross of Idaho's Healthcare Operations department will notify the provider of the authorization decision by secure email, mail, phone, or fax. Authorization period may not exceed three months without review of medical records. If medical necessity justifies special handling, include an explanation and note that expedited handling may be considered when delay could seriously jeopardize the member's life, health, or ability to regain maximum function (provider attestation required).
Fax the completed form along with medical records documenting the clinical indications or medical necessity to the appropriate fax number listed on the form. For questions, contact the numbers provided on the form. Please submit elective prior authorization requests at least 10 days prior to the scheduled date of service. Missing or incomplete data on the form may result in an authorization delay.
Requested CPT and Procedure Codes
| CPT Code(s) requested | Place to list the CPT procedure codes for the requested ECT treatments |
Prior Authorization & Provider Requirements
Prior authorization required using the ECT request form
Prior authorization for ECT must be requested using the Blue Cross of Idaho ECT request form with all requested clinical information completed; submission by fax or phone does not itself authorize services and the plan will notify the provider of its decision. Authorization periods may not exceed three months without review of medical records; include an explanation if special handling is requested and submit elective requests at least 10 days before the service date.
- Fax the completed form and supporting medical records to the appropriate fax number listed on the form.
- If delaying the service could seriously jeopardize the member, have the medical provider sign the expedited attestation per PAP 241.
Document prior medication and ECT treatment history
Provide a complete treatment history including prior medication trials (current and past medications with dose, duration, and response) and any prior ECT series with dates and outcomes to document prior therapeutic attempts before ECT when applicable.
- List current medications with dose, duration, and response.
- List past medication history with dose, duration, and response.
- Document any prior ECT series with dates and locations and outcomes.
Required supporting documentation (psychiatric evaluation and rating scales)
Submit supporting clinical records with the form: the most recent psychiatric evaluation referring the patient to ECT and any rating scales used to demonstrate the member's decline in functioning, plus medical records documenting clinical indications or medical necessity.
- Attach the most recent psychiatric evaluation that refers the patient to ECT.
- Include any rating scales used to show decline in functioning.
Provide required clinical details on the form
Complete the clinical detail sections on the form: treatment history (outpatient and inpatient with dates, locations, and lengths of stay), current and past medication history (dose, duration, response), pre-ECT workup completion and clearance, informed consent status, coordination of care, and reason for referral.
- Indicate whether a current medical assessment and pre-ECT workup have been completed and whether clearance was given.
- Confirm informed consent has been obtained from the patient or guardian.
- Provide dates, locations, and lengths of stay for inpatient/outpatient treatment history and names/contacts for coordinating providers.
Incomplete submission may delay or impede authorization
Incomplete or missing information on the form may result in an authorization delay; all information requested on the form must be complete to avoid processing delays.
- Missing data may result in authorization delay—ensure all fields and required attachments are provided.
- Elective prior authorization requests should be submitted at least 10 days before the scheduled date of service to avoid delays.
Purpose and Scope
This form is intended to document clinical indications and medical necessity for initiating short-term or acute courses of electroconvulsive therapy (ECT). It requests the presenting problem, diagnoses (including mental and substance use disorders and relevant medical conditions), and the number and frequency of treatments requested.
The form also requires complete treatment and medication history (current and past medications with dose, duration, and response), documentation of any prior ECT series and outcomes, evidence of a completed pre-ECT medical assessment and clearance, informed consent, and supporting psychiatric evaluation and rating scales to demonstrate functional decline.
Pre-ECT Workup and Authorization Details
ECT Treatment Details
ECT
Authorization Period and Visit Limits
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