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ModifiedcurativePolicy CHP-OP-2026-061

Behavioral Health - TMS and ECT Therapies

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This policy establishes medical-necessity criteria for repetitive transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT), including initial, continuation, maintenance, and re-treatment courses. It applies to all plan types and treatment settings where these services are delivered, subject to device clearances, applicable state requirements, and parity rules.

Policy Summary

Payercurative

PolicyBehavioral Health - TMS and ECT Therapies

Policy CodePolicy CHP-OP-2026-061

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionApply the corrected Texas ECT requirements, including the minimum age of 16, written consent on the required state form, and physician confirmation for patients age 65 or older.

SourceLink

POLICY UPDATE CHANGES

The policy corrects the Texas ECT requirements to reflect the statutory prohibition for persons younger than 16, required written consent on a state form, and physician confirmation requirements for persons age 65 and older.

2Covered treatment modalities

18+Adult-cleared TMS device age

15-17Adolescent-cleared TMS age

13+FDA-classified ECT age

2Adequate antidepressant trials generally required for TMS for MDD

Covered Treatment Modalities

TMS: modality overview and treatment criteria

TMS is covered for specified psychiatric indications when the applicable diagnosis, severity, treatment history, age, safety, device, and protocol requirements are met.

Covered TMS indications: TMS is medically necessary for an initial major depressive disorder course when all MDD criteria are met, or for adult obsessive-compulsive disorder when all OCD criteria are met, using a device and protocol cleared for the requested indication and age.MDD: adults 18 and older, or ages 15 to 17 with an adolescent-cleared device used as an adjunct; OCD: adults 18 and older

TMS for non-cleared indications or protocols is experimental, investigational, or unproven.

ECT: modality overview and treatment criteria

ECT is covered for qualifying index-course indications and for continuation or maintenance when response and ongoing measurement requirements are documented.

Covered ECT courses:

Policy Summary

Payercurative

PolicyBehavioral Health - TMS and ECT Therapies

Policy CodePolicy CHP-OP-2026-061

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionApply the corrected Texas ECT requirements, including the minimum age of 16, written consent on the required state form, and physician confirmation for patients age 65 or older.

SourceLink

On This Page

ECT is medically necessary for a qualifying index-course clinical indication, or for continuation or maintenance after a documented response with a defined schedule, periodic symptom and cognitive measurement, and reassessment of the need to continue.

Generally age 13 and older under FDA classification, subject to state law and child-and-adolescent psychiatry review requirements

State minimum-age, consent, and physician-confirmation requirements apply where applicable.

TMS: device-cleared modality requirements

Covered TMS must use the particular device and protocol cleared for the requested indication and age.

TMS device and indication requirements: Use a device and protocol cleared for the requested indication and age range; for major depressive disorder, document the required diagnosis, validated symptom severity, and adequate antidepressant treatment history or documented intolerance or contraindication.Adult-cleared devices: 18 years and older; adolescent-cleared device: 15 to 21 years as an adjunct

Accelerated TMS is covered only when delivered with a device and protocol specifically cleared for accelerated delivery. Eligibility is determined by the clearance of the particular device requested.

ECT: state-law and modality requirements

ECT must satisfy the FDA classification and the law of the state where treatment is provided.

ECT state-law and modality requirements: A qualifying ECT indication, pre-ECT psychiatric and anesthesia evaluations, required risk-benefit and mitigation planning, informed consent, and baseline symptom and cognitive assessments must be documented; treatment must also comply with the applicable state minimum age, consent form, and physician-confirmation requirements.FDA classification: generally age 13 and older; state law may establish a higher minimum age

Requests involving younger members require child and adolescent psychiatrist review. Texas prohibits ECT for persons younger than 16, requires written consent on a state form, and requires two physicians to confirm medical necessity for persons age 65 and older.

Medical Necessity and Coverage Criteria

Initial TMS for major depressive disorder

Covered when ALL of the following are met; the pharmacotherapy subsection uses ANY-of logic.

Initial TMS for MDD

ONE pharmacotherapy pathway
- Two adequate trials: Failure of, or documented intolerance to, at least two adequate antidepressant trials in the current or prior episodes; the trials need not be from different classes.At least 2 adequate trials
- One current-episode trial plus inability to continue: Failure of at least one adequate antidepressant trial in the current episode plus documented intolerance of, or medical contraindication to, further antidepressant trials.At least 1 current-episode adequate trial
- Medication contraindication: A medical contraindication to antidepressant medication.
Diagnosis and treatment direction: DSM-5-TR major depressive disorder, single or recurrent episode, without psychotic features, confirmed by an appropriately licensed clinician, with a physician-directed TMS treatment plan.
Severity: Current symptom severity is at least moderate and documented with a validated instrument, including the instrument and score.At least moderate
Examples include PHQ-9, HAM-D, MADRS, or QIDS.
Age and device clearance: The member's age is within the cleared indication for the device used.18 and older for adult-cleared devices; 15 to 17 only with an adolescent-cleared device
Adolescent use must be adjunctive to ongoing treatment.
Safety and protocol: Pre-treatment screening documents no incompatible conductive, ferromagnetic, or other magnet-sensitive metal or implanted stimulator unless device labeling permits treatment; seizure risk has been assessed with a risk-benefit determination and mitigation plan when indicated; and the requested course follows the cleared device protocol with repeated severity measurement.

TMS for obsessive-compulsive disorder

Covered when ALL of the following are met.

TMS for OCD: The member is an adult with DSM-5-TR obsessive-compulsive disorder of at least moderate severity documented with the Yale-Brown Obsessive Compulsive Scale; TMS is adjunctive to ongoing OCD treatment with an adequate therapeutic-dose serotonin reuptake inhibitor trial, exposure and response prevention therapy, or both, that has not produced an adequate response or caused documented intolerance; and an OCD-cleared device is used according to its cleared protocol with the safety screening required for MDD.Age 18 or older; at least moderate severity; pivotal study enrolled scores above 20 on the Yale-Brown Obsessive Compulsive Scale

ECT index course

Covered when ALL of the following are met; the clinical-indication subsection uses ANY-of logic.

ONE qualifying ECT indication
- Severe treatment-resistant or urgent depression: A severe major depressive episode associated with major depressive disorder or bipolar disorder is treatment-resistant or requires a rapid response because of psychiatric or medical severity.
- Psychotic or catatonic depression: Depression has psychotic or catatonic features.
- Urgent response need: There is an acute suicidality or refusal of food or fluids with nutritional compromise, or another urgent need for response.
- Catatonia from any cause is present, including catatonic symptoms not resolved by benzodiazepine treatment.

Sequencing and parity rules

These administration rules apply to covered TMS and ECT services.

Sequencing and parity rules: A trial of psychotherapy is not a prerequisite to TMS; exhausted pharmacotherapy is not required before ECT when an urgent indication, psychotic or catatonic features, prior response, or patient preference is present; neither modality requires a prior trial of the other; and session limits, review frequency, prior authorization, fail-first requirements, medical-necessity criteria, network standards, and other nonquantitative treatment limitations must be comparable to and no more stringent than those applied to comparable medical or surgical services.

A written NQTL comparative analysis must be maintained for plans subject to MHPAEA. Automated systems and non-physician reviewers may approve but may not deny; adverse medical-necessity determinations require licensed-physician review after an offered peer-to-peer discussion.

Continuation, maintenance, and re-treatment

Continuation, maintenance, or re-treatment is medically necessary when ANY of the following is documented.

ONE qualifying continuation, maintenance, or re-treatment circumstance

TMS acute-course extension: There is partial response during the acute course with continued improvement on the validated measure, and the cleared or published protocol supports additional sessions.
TMS re-treatment: There is relapse after a prior TMS course that produced a documented response; the request is reviewed as continuation rather than as a new first-line request and does not require new medication trials.
Maintenance TMS: There was a documented response to TMS, with relapse or high relapse risk despite continuation pharmacotherapy, and a defined session schedule with periodic measurement is provided.
ECT index-course continuation:

TMS does not meet criteria

TMS does not meet criteria when any of the following circumstances applies.

ONE TMS documentation or indication failure: Major depressive disorder is not confirmed; symptom severity is not documented with a validated instrument; no adequate antidepressant trial is documented; or no intolerance or contraindication is documented when relying on that alternative.

The request is referred for physician review; it is not denied by an automated system or non-physician reviewer.

Unproven TMS

TMS is considered experimental, investigational, or unproven when any of the following applies.

ONE unsupported TMS indication or protocol: The indication is neither FDA-cleared for the device used nor guideline-supported; the treatment is for smoking cessation under this behavioral-health policy; the patient is outside the device-cleared age range; or the protocol is EEG-guided, synchronized, or otherwise not FDA-cleared and lacks evidence of comparable effectiveness.

Examples of unsupported indications include bipolar depression, PTSD, schizophrenia, generalized anxiety disorder, autism, and substance use disorders outside a cleared indication. Smoking-cessation TMS is referred for physician review under this policy.

Continuation and maintenance treatment

Continuation or maintenance treatment does not meet medical-necessity criteria when either condition applies.

ONE absence of demonstrated benefit: There is no documented response to the prior TMS or ECT course, or periodic symptom or cognitive outcome measurement has not been performed.

The policy requires demonstrated benefit to maintain or continue treatment; the request is not medically necessary when benefit has not been demonstrated.

ECT state-law requirements

ECT does not meet policy requirements when either condition applies.

ONE violation of applicable state requirements: The member is below the statutory minimum age in the state where treatment is provided, or statutorily required consent has not been obtained.

State law may impose a higher minimum age than the FDA classification. Texas prohibits ECT for persons younger than 16 and requires written consent on a state form; additional state-specific physician-confirmation requirements may apply.

This policy addresses medical-necessity criteria for psychiatric TMS and ECT, including initial, continuation, maintenance, and re-treatment courses. It does not govern ECT anesthesia, facility, or inpatient level-of-care determinations; vagus nerve stimulation, deep brain stimulation, esketamine or ketamine treatment; or TMS for non-psychiatric indications such as migraine.

TMS for smoking cessation is outside the criteria of this behavioral-health policy, even when a specific device has FDA clearance for that use. Requests for this indication are referred for physician review rather than handled under the policy's covered TMS criteria.

TMS is considered experimental, investigational, or unproven when the requested indication is neither FDA-cleared for the device used nor guideline-supported. Examples include bipolar depression, PTSD, schizophrenia, generalized anxiety disorder, autism, and substance use disorders outside a cleared indication.

EEG-guided, synchronized, or other TMS protocols that are not part of an FDA clearance and lack evidence of comparable effectiveness are considered experimental, investigational, or unproven.

ECT does not meet policy requirements when provided below the applicable state's statutory minimum age or without legally required consent. State law where the service is provided controls and may impose requirements more restrictive than the FDA classification.

Continued or maintenance TMS or ECT is not medically necessary when there is no documented response to the prior course or when periodic symptom or cognitive measurement has not been performed. Continued treatment requires demonstrated benefit and appropriate reassessment.

TMS does not meet medical-necessity criteria when MDD is not confirmed, symptom severity is not documented with a validated instrument, or an adequate antidepressant trial, intolerance, or contraindication is not documented. Such requests are referred for physician review rather than denied by an automated system or non-physician reviewer.

Marked or progressive cognitive impairment during ECT, such as disorientation or significant anterograde amnesia, requires clinical management. The treating team should modify the technique—for example, electrode placement, pulse width, or treatment frequency—and reassess; the finding prompts modification rather than automatic discontinuation.

Maintenance, continuation, or re-treatment with TMS or ECT requires documentation of response to the prior course and periodic symptom or cognitive measurement, as applicable. Without documented benefit or ongoing measurement, the treatment does not meet medical-necessity criteria.

Coding and Eligibility Reference

TMS for MDD and OCDCPTCovered

90867	TMS for major depressive disorder or obsessive-compulsive disorder
90868	TMS for major depressive disorder or obsessive-compulsive disorder
90869	TMS for major depressive disorder or obsessive-compulsive disorder

ECTCPTCovered

90870

ECT index course

TMS procedure codes listed for referenceCPT

90867	TMS initial session with motor threshold and mapping
90868	TMS subsequent delivery and management
90869	TMS subsequent motor threshold re-determination

Electroconvulsive therapyCPT

90870

Electroconvulsive therapy

Adequate antidepressant trial

Therapeutic doseAntidepressant taken at a therapeutic dose

Minimum durationAt least 4 weeks

Intolerance exceptionA shorter trial may qualify when stopped because of documented intolerance

TMS for major depressive disorder

Minimum severityAt least moderate current symptom severity

Required instrumentA validated symptom-severity instrument

DocumentationRecord the instrument and score; examples include PHQ-9, HAM-D, MADRS, or QIDS

TMS for obsessive-compulsive disorder

Minimum severityAt least moderate OCD severity

Validated scaleYale-Brown Obsessive Compulsive Scale

Pivotal-study thresholdThe pivotal study enrolled members with scores above 20

TMS antidepressant history

Standard pathwayFailure of, or documented intolerance to, at least two adequate antidepressant trials; trials need not be from different classes

One-trial pathwayFailure of at least one adequate current-episode trial plus documented intolerance of, or medical contraindication to, further trials

Medication contraindicationA medical contraindication to antidepressant medication

Treatment age

Adult-cleared TMS devicesAdults 18 and older

Adolescent-cleared TMS devicesAges 15 to 17 only with a device whose FDA clearance includes that age; use is adjunctive to ongoing treatment

ECTAge 13 and older under FDA classification; younger ages require physician review and state law may set a higher minimum age

Adult TMS device age

Minimum age18 years and older

Applicable treatmentTMS using an adult-cleared device

Age limitationTreatment is limited to the cleared age range of the device

Adolescent-cleared TMS device age

Age range15 to 21 years

Treatment roleAdjunct to ongoing treatment

Clearance requirementThe specific device must be cleared for adolescent use

ECT FDA-classification age

FDA-classification minimum age13 years and older

Younger childrenRequests below age 13 require child psychiatry review

State-law limitationA state law where treatment is provided may set a higher minimum age

Adequate antidepressant trial

Minimum durationAt least 4 weeks

Dose requirementTreatment must be at a therapeutic dose

Early discontinuationDiscontinuation because of documented intolerance may count as a failed trial

Authorization, Documentation, and Review Requirements

Prior Authorization

Parity-Compliant Utilization Management

Apply prior authorization, concurrent review, fail-first or step requirements, medical-necessity criteria, network standards, and other nonquantitative treatment limitations to TMS and ECT no more stringently than comparable medical/surgical benefits in the same classification. Maintain the required NQTL comparative analysis, including for ERISA self-funded plans subject to MHPAEA.

Denial Risk

Physician Review for Adverse Determinations

Automated systems and non-physician reviewers may approve requests, in whole or in part, but may not issue an adverse determination. After offering the requesting provider a peer-to-peer discussion, every adverse medical-necessity determination must be made by a licensed physician meeting applicable specialty, licensure, and state requirements.

Documentation Required

Texas ECT Requirements

Before providing ECT in Texas, confirm compliance with the statutory minimum age, written-consent requirements, and physician-confirmation requirement. ECT may not be used for a person younger than 16; for a person age 65 or older, two physicians must sign a medical-necessity statement before each treatment series begins.

Written consent must meet statutory content requirements.
Texas Health and Safety Code §§ 578.002 and 578.003.

Note

State Review Variances

Apply state-specific behavioral-health utilization and medical-necessity rules by place of service and applicable plan type. Illinois restricts authorization and concurrent review in specified circumstances beginning January 1, 2026; New Mexico bars authorization for specified acute or initial in-network care; California requires generally accepted standards and nonprofit specialty criteria; Washington requires generally accepted standards beginning January 1, 2027. Georgia also requires generally accepted standards and statutory medical-necessity definitions for applicable determinations.

Verify current effective dates, funding type, network status, notice requirements, and service setting.
Review applicable Illinois, New Mexico, California, Washington, and Georgia law before applying plan controls.

Prior Authorization

Separate Initial and Subsequent TMS Authorization

Authorize the initial TMS request as one acute course under the device’s cleared protocol. Review additional sessions, retreatment, continuation, and maintenance separately under the applicable response, relapse-risk, measurement, and schedule requirements; do not treat later treatment as automatically included in the initial authorization.

Initial authorization covers one acute course.
Subsequent treatment requires separate continuation or maintenance review.

Denial Risk

Physician Review Required for Denials

Only a licensed physician may issue an adverse determination after peer-to-peer opportunity. Automated systems and non-physician clinical reviewers may approve a request in full or in part, but a request that does not meet criteria must be referred for physician review.

Prior Authorization

Approve the Supported Portion

When the service meets medical-necessity criteria but the requested quantity, units, or duration exceed the documentation, approve the supported portion and refer only the unsupported increment for physician review rather than denying the entire request.

Apply this rule to excess sessions, units, or treatment duration.

Step Therapy

No Psychotherapy Prerequisite for TMS

Do not require a trial of psychotherapy before TMS. The cleared indications and applicable guideline support condition TMS on medication non-response, intolerance, or contraindication—not psychotherapy non-response. Concurrent psychotherapy is encouraged and separately covered.

Step Therapy

No Mandatory Medication Exhaustion Before Indicated ECT

Do not require exhaustion of pharmacotherapy before ECT when an urgent indication, psychotic or catatonic features, prior positive response, or informed patient preference supports ECT. Urgent cases must not be delayed for additional medication trials.

Step Therapy

No Cross-Modality Fail-First Requirement

Do not impose cross-modality fail-first requirements. A prior TMS trial is never required before ECT, and a prior ECT trial is never required before TMS when the requested treatment independently meets medical-necessity criteria.

Documentation Required

TMS for MDD Documentation

For an initial TMS course for MDD, document the diagnosis, treatment plan, current severity, medication-treatment history, age/device eligibility, safety screening, seizure-risk assessment, cleared protocol, and plan for repeat measurement.

DSM-5-TR MDD diagnosis confirmed by a qualified clinician; physician-directed treatment plan.
Validated severity instrument, score, and date; at least moderate current severity.
Adequate antidepressant failures, intolerance, or contraindication.
Device-cleared age range, implant and metal screening, seizure-risk mitigation, and cleared treatment parameters.

Documentation Required

TMS for OCD Documentation

For TMS for OCD, document an adult member’s DSM-5-TR OCD diagnosis, at least moderate severity, prior treatment, and use of an OCD-cleared device under its cleared protocol with required safety screening.

Document the Yale-Brown Obsessive Compulsive Scale score.
Document an adequate serotonin-reuptake-inhibitor trial, exposure and response prevention, or both, or documented intolerance.

Documentation Required

ECT Index-Course Documentation

For an ECT index course, document a qualifying clinical indication, pre-ECT psychiatric evaluation, anesthesia evaluation, medical risk assessment and mitigation plan, informed consent compliant with state law, baseline symptom and cognitive measures, and a plan for repeat assessment.

Indications may include severe or treatment-resistant depression, psychotic or catatonic features, urgent need for response, catatonia, severe or treatment-resistant mania, specified refractory psychotic disorders, prior positive response, or informed patient preference.
Include medical history, examination, medications, anesthesia risks, state-required consent, and any physician statement.

Denial Risk

Red-Flag Documentation and Escalation

Escalate urgent or high-risk findings for expedited clinical review and address the underlying safety issue before treatment proceeds. Suicidality, food or fluid refusal with compromise, catatonia, psychosis, seizures, device incompatibility, cognitive decline, or emerging mania can change the treatment pathway.

Active suicidality or nutritional compromise may support same-day ECT review and inpatient evaluation.
Catatonia may require emergency evaluation for malignant catatonia or neuroleptic malignant syndrome.
Psychosis referred for TMS requires psychiatric reassessment and consideration of ECT or antipsychotic augmentation.
Stop TMS after a seizure and do not resume until neurological and risk-benefit review.
Do not treat with TMS until ferromagnetic or implanted electronic-device compatibility is confirmed.

Documentation Required

Continuation and Maintenance Documentation

For continuation, maintenance, or retreatment, document response to the prior course, current symptom and cognitive measures as applicable, the relapse or relapse-risk rationale, defined treatment schedule, and periodic reassessment plan.

Document continued improvement for an acute-course extension.
Document prior response for retreatment or maintenance TMS.
Document response to the ECT index course and periodic symptom and cognitive measurement for continuation or maintenance ECT.

Documentation Required

Diagnostic and Treatment-History Records

Include the DSM-5-TR diagnosis and confirming clinician, baseline validated severity score with instrument, score, and date, repeat scores, and complete treatment history. For TMS, include medication, dose, dates, therapeutic duration, adherence, response, intolerance, or contraindication.

Documentation Required

TMS Device and Safety Documentation

For TMS, document the device name, cleared indication, protocol, implant and metal safety screening, and seizure-risk assessment. Confirm that the requested coil, parameters, schedule, and session count follow the device’s cleared protocol.

Address conductive, ferromagnetic, or other magnetic-sensitive metal within 30 cm of the coil.
Document implanted stimulators or electrodes and any labeling-based compatibility determination.
Document seizure history, threshold-lowering conditions, risk-benefit assessment, and mitigation plan.

Documentation Required

ECT Evaluation and Consent Documentation

For ECT, include the treating psychiatrist’s evaluation, anesthesia evaluation, medical-risk assessment, baseline cognitive assessment, informed consent, and any state-required consent form or physician statement. Document the ECT indication category and risk-benefit mitigation plan when applicable.

Include urgent indication, psychotic or catatonic features, treatment resistance, prior response, or patient preference.
Confirm compliance with the law of the state where services are provided.

Unsupported block type: denial_risk

Unsupported block type: documentation

Unsupported block type: denial_risk

Clinical Background

TMS uses a magnetic coil to stimulate superficial cortical neurons and is covered only for the FDA-cleared indication, age range, device, and protocol requested. Adult-cleared devices generally apply to members age 18 and older; adolescents ages 15 to 17 may be treated only with an adolescent-cleared device and as an adjunct to ongoing treatment. Accelerated TMS likewise requires a device and protocol specifically cleared for accelerated delivery. ECT induces a therapeutic generalized seizure under general anesthesia and neuromuscular blockade and is FDA-classified for patients age 13 and older, subject to applicable state-law age, consent, and review requirements.

Policy Definitions

Adequate antidepressant trial

DefinitionAn antidepressant taken at a therapeutic dose for at least 4 weeks

Response-assessment contextThe APA guideline describes 4 to 8 weeks as generally needed to judge response

ExceptionA shorter trial may qualify when stopped because of documented intolerance

Response

DefinitionA clinically meaningful reduction in symptom severity

Measurement methodUse the same validated scale used at baseline

Conventional thresholdAt least a 50 percent reduction from baseline

Index (acute) course

TMS index courseThe initial series of TMS sessions delivered according to the cleared protocol

ECT index courseThe initial series of ECT treatments

ECT course endpointECT continues until remission or a plateau in improvement

Continuation and maintenance treatment

TimingTreatment provided after a documented response

ContinuationTreatment intended to prevent relapse, generally during the first months after response

MaintenanceLonger-term treatment intended to prevent recurrence

Adequate antidepressant trial

Minimum durationAt least 4 weeks

DoseTreatment must be at a therapeutic dose

Intolerance exceptionEarly discontinuation because of intolerance may count as a failed trial

Accelerated TMS

DefinitionA TMS protocol delivered with a device and protocol specifically cleared for accelerated delivery

Device requirementThe device must have clearance for the accelerated protocol

Protocol requirementAccelerated delivery must follow the cleared protocol

Device-cleared indication

DefinitionA TMS indication and protocol cleared by FDA for the particular device requested

Eligibility standardEligibility is determined by the specific device clearance, rather than by manufacturer generally

Protocol requirementThe requested treatment must use the cleared indication and protocol

Treatment Authorization Limits

TMS initial authorization scope

Initial authorizationOne acute course

ProtocolThe course must follow the device's cleared protocol

ScopeThe limit applies to the initial TMS authorization

TMS additional sessions

Additional sessionsRequire continuation criteria

Review timingApplies after the initial acute course

DocumentationSupporting documentation is required for subsequent sessions

Other severe or treatment-resistant illness: Severe or treatment-resistant mania, neuroleptic malignant syndrome not responding to initial management, or treatment-resistant schizophrenia or schizoaffective disorder, including inadequate response to clozapine, is present and supported by APA guidance.

Prior response or preference: There has been a prior positive response to ECT or the patient has an informed preference for ECT.

Pre-ECT and anesthesia evaluation: The treating psychiatrist and anesthesia clinician document medical history, examination, medications, risk-increasing conditions, and a risk-benefit determination and mitigation plan when such a condition is present.

Examples include recent myocardial infarction, unstable cardiac disease, increased intracranial pressure, recent stroke, or vascular aneurysm.

Consent and age: Informed consent complies with state law, including any state minimum age, consent form, or physician-confirmation requirement; the age requirement is satisfied or younger-age treatment is referred for child and adolescent psychiatrist review.

Measurement: A baseline validated symptom measure and baseline cognitive assessment are documented with a plan to repeat them during the course.

There is continued improvement on the validated measure without plateau, reassessed at regular intervals during the series.

Continuation or maintenance ECT: There was a response to the index course, particularly when medication or psychotherapy has been ineffective in maintaining remission or prior episodes responded only to ECT, with a defined schedule, periodic symptom and cognitive measurement, and periodic reassessment of the need to continue.