CurrentlucetPolicy N/A

Continuation and Maintenance Outpatient Electroconvulsive Therapy (ECT) Coverage Criteria

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This form and policy govern requests for continuation and maintenance outpatient ECT, describing required documentation, clinical criteria, and billing units for Lucet-covered members. It applies to providers requesting authorization or submitting continuation/maintenance ECT requests for covered members.

Policy Summary

Payerlucet

PolicyContinuation and Maintenance Outpatient Electroconvulsive Therapy (ECT) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionUse the Lucet authorization form and include CPT codes 00901 and 90870 when requesting continuation or maintenance outpatient ECT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Continuation: 6/6moauthorized treatment allowance

Maintenance: 24/yrauthorized treatment allowance

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CurrentlucetPolicy N/A

Continuation and Maintenance Outpatient Electroconvulsive Therapy (ECT) Coverage Criteria

Customize your policy alerts

Sign up for all lucet policy alerts

Know when lucet releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payerlucet

PolicyContinuation and Maintenance Outpatient Electroconvulsive Therapy (ECT) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionUse the Lucet authorization form and include CPT codes 00901 and 90870 when requesting continuation or maintenance outpatient ECT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Continuation: 6/6moauthorized treatment allowance

Maintenance: 24/yrauthorized treatment allowance

Psychiatrist ECT code

00901Facility ECT code

Coverage Criteria — Continuation and Maintenance ECT

Continuation Therapy

Covered when ALL of the following are met for Continuation ECT:

Continuation ECT criteria: 1) Attending psychiatrist performs assessment of current symptoms and medications; determines the need for Continuation ECT and timing/frequency of treatments. 2) Member has shown an adequate response to the initial episode of ECT. 3) Member prefers continuation ECT OR is intolerant to pharmacotherapy. 4) Member or guardian provides informed consent and is educated concerning the risks and benefits.

Maintenance Therapy

Covered when ALL of the following are met for Maintenance ECT:

Maintenance ECT criteria: 1) Attending psychiatrist performs assessment of current symptoms and medications; determines the need for Maintenance ECT and timing/frequency of treatments. 2) Member has shown an adequate response to the continuation of ECT. 3) Member has a marked history of relapse and recurrence OR has significant symptom increases when Continuation ECT was tapered. 4) Member prefers Maintenance ECT OR is intolerant to pharmacotherapy. 5) Member or guardian provides informed consent and is educated concerning the risks and benefits.

Authorization is not required for members whose coverage is through BCBS Alabama, BCBS Kansas, or BCBS Arkansas.

Billing Codes and Unit Limits

Covered CPT CodesCPTCovered

00901	Electroconvulsive Therapy Facility (Facility)
90870	Electroconvulsive Therapy Treatment and Monitoring (Psychiatrist)

inv-05: Continuation units — 6 units / 6 months

Authorized allowance6 units per 6 months for Continuation ECT

Applicable CPT codesCPT 90870 (Psychiatrist) and CPT 00901 (Facility) as applicable

Clinical prerequisitesAttending psychiatrist assessment; demonstrated adequate response to initial ECT; patient preference for continuation ECT or intolerance to pharmacotherapy; informed consent and education documented

Documentation noteCheck the Continuation box on the form to attest criteria have been met

inv-06: Maintenance units — 24 units / 1 year

Authorized allowance24 units per 1 year for Maintenance ECT

What Providers Must Do

Billing Rule

Authorization submission and billing codes

Use this Lucet continuation/maintenance outpatient ECT request form to submit authorization requests; include the applicable CPT procedure codes on the form and claim: 00901 (Electroconvulsive Therapy Facility) and 90870 (Electroconvulsive Therapy Treatment and Monitoring). Return the completed form via fax to the appropriate Lucet fax number for review (e.g., Lucet Employee: 816-416-7788 or Internal Behavioral Health Benefit Review team: 816-237-2364).

Include CPT 00901 and CPT 90870 on the request form/claim.
Fax completed form to the appropriate Lucet fax number listed on the form/instructions.

Step Therapy

Clinical sequencing requirement

Document that the member has shown an adequate response to the prior ECT course (initial for continuation requests; continuation for maintenance requests) and that the member either prefers continuation/maintenance ECT or is intolerant to pharmacotherapy.

Background

Electroconvulsive therapy (ECT) may be used as a continuation or maintenance treatment following an initial ECT course for patients who have responded to ECT or who cannot tolerate pharmacotherapy. Continuation ECT is requested when the attending psychiatrist documents an adequate response to the initial ECT episode and determines that ongoing treatments and a specified frequency are needed, with documentation of patient preference or intolerance to medication and informed consent. Maintenance ECT is indicated when the member has demonstrated benefit from continuation ECT and has a marked history of relapse/recurrence or significant symptom worsening when continuation ECT was tapered; the psychiatrist must document the need for ongoing maintenance treatments, patient preference or intolerance to pharmacotherapy, and informed consent.

Definitions — Continuation and Maintenance ECT

inv-12: Definition — Continuation ECT requirements and documentation expectations

DefinitionContinuation ECT must be requested when the member has shown an adequate response to the initial episode of ECT and the psychiatrist determines ongoing treatments and frequency are needed; member preference or intolerance to pharmacotherapy and informed consent must be documented.

Attending psychiatrist rolePerform assessment of current symptoms and medications; determine need and timing/frequency of Continuation ECT.

Consent and educationMember or guardian must provide informed consent and be educated concerning risks and benefits.

Form actionCheck the Continuation box on the form to attest that all criteria are met.

inv-13: Definition — Maintenance ECT requirements and documentation expectations

Definition

Level of Care — Outpatient ECT

Treatment Modalities — ECT

ECT

ECT modality criteria: Continuation and maintenance outpatient ECT require attending psychiatrist assessment, documented response to prior ECT, documented preference for ECT or intolerance to pharmacotherapy, and informed consent.

Visit Limits and Authorized Units

inv-16: Continuation ECT (90870/00901 as applicable) — 6 units

Service limitContinuation ECT (90870/00901 as applicable): 6 units per 6 months

Associated CPT codes90870 (Electroconvulsive Therapy Treatment and Monitoring — Psychiatrist); 00901 (Electroconvulsive Therapy Facility)

Clinical conditionRequires attending psychiatrist assessment and documented adequate response to initial ECT

inv-17: Maintenance ECT (90870/00901 as applicable) — 24 units

Service limitMaintenance ECT (90870/00901 as applicable): 24 units per 1 year

Associated CPT codes90870 (Electroconvulsive Therapy Treatment and Monitoring — Psychiatrist); 00901 (Electroconvulsive Therapy Facility)

Policy Summary

Payerlucet

PolicyContinuation and Maintenance Outpatient Electroconvulsive Therapy (ECT) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionUse the Lucet authorization form and include CPT codes 00901 and 90870 when requesting continuation or maintenance outpatient ECT.

SourceLink

On This Page

Applicable CPT codesCPT 90870 (Psychiatrist) and CPT 00901 (Facility) as applicable

Clinical prerequisitesAttending psychiatrist assessment; demonstrated adequate response to continuation ECT; marked history of relapse/recurrence or symptom worsening when continuation ECT tapered; patient preference for maintenance ECT or intolerance to pharmacotherapy; informed consent and education documented

Documentation noteCheck the Maintenance box on the form to attest criteria have been met

For continuation: adequate response to the initial episode of ECT plus preference or intolerance to pharmacotherapy.
For maintenance: adequate response to continuation ECT plus preference or intolerance to pharmacotherapy and relapse/recurrence history as applicable.

Documentation Required

Required documentation and form completion

Complete the form neatly and fully; include numerical diagnosis code(s) from DSM-5 or ICD-10, patient demographics, and the authorization number, and attest that the attending psychiatrist has completed the required assessment and documented response, preference/intolerance to pharmacotherapy, and informed consent.

Type or print neatly and complete all applicable fields.
Include numerical diagnosis code(s) from DSM-5 or ICD-10, patient name, DOB, insurance policy number, and Authorization Number.
Attest that the attending psychiatrist performed the assessment, documented response to prior ECT, patient preference or pharmacotherapy intolerance, and informed consent.

Denial Risk

Missing required clinical criteria — risk for denial

Requests that do not document all required clinical criteria — including the attending psychiatrist's assessment, demonstrated adequate response to prior ECT as applicable, documented preference or intolerance to pharmacotherapy, and informed consent — may be incomplete and are at risk for denial.

Missing documentation of the psychiatrist's assessment, prior ECT response, patient preference/intolerance, or informed consent can lead to denial.

Maintenance ECT requires documentation that the member has shown adequate response to continuation ECT, has a marked history of relapse/recurrence or significant symptom increases when Continuation ECT was tapered, and that the member prefers Maintenance ECT or is intolerant to pharmacotherapy, plus informed consent and education.

Attending psychiatrist rolePerform assessment of current symptoms and medications; determine need and timing/frequency of Maintenance ECT.

Clinical thresholdDocumented history of relapse/recurrence OR symptom worsening when Continuation ECT tapered is required for maintenance consideration.

Form actionCheck the Maintenance box on the form to attest that all criteria are met.

Clinical conditionRequires attending psychiatrist assessment and documented adequate response to continuation ECT plus relapse/recurrence history or symptom worsening when tapering