CurrentlucetPolicy N/A

REQUEST FOR CONTINUATION OR MAINTENANCE OUTPATIENT ELECTROCONVULSIVE THERAPY (ECT)

Form and coverage criteria for continuation and maintenance outpatient ECT, including required clinician assessments, patient response/intolerance criteria, consent, and billing units/codes. Applies to requests for continuation or maintenance outpatient ECT; includes instructions for submission and lists CPT codes and unit limits.

Policy Summary

Payerlucet

PolicyREQUEST FOR CONTINUATION OR MAINTENANCE OUTPATIENT ELECTROCONVULSIVE THERAPY (ECT)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete all member identifying fields and required clinical information on the form and submit via fax to the appropriate number for the member's plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

2Covered Indications (Continuation, Maintenance)

2Required clinician assessments

2Unit limitations (continuation/maintenance)

Coverage Summary

This form and coverage criteria address Continuation and Maintenance Outpatient Electroconvulsive Therapy (ECT). Lucet covers these services with criteria — requests must meet the specified clinical requirements for continuation or maintenance outpatient ECT and follow the submission instructions on the form.

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Key coverage summary

Scope summaryForm and criteria for continuation and maintenance outpatient ECT; includes required clinician assessments, patient response/intolerance criteria, informed consent, CPT codes, unit limits, and submission instructions.

Coverage stanceCovered with criteria (continuation and maintenance outpatient ECT require specified clinical criteria).

StatusCURRENT

Applicable indications count2 (Continuation, Maintenance)

Unit limitations summaryContinuation: 6 units per 6 months; Maintenance: 24 units per 1 year (CPT codes 00901, 90870).

Medically Necessary Criteria

Continuation ECT - Medically Necessary Criteria

Must meet all of the following:

ALL of the following

The attending psychiatrist performs an assessment of current symptoms and medications.
The attending psychiatrist determines the need for Continuation ECT.
The attending psychiatrist determines the timing and frequency of treatments.
The member has shown an adequate response to the initial episode of ECT.
ONE of
- The member expresses a preference to continuation ECT.
- The member is intolerant to pharmacotherapy.
The member or guardian provides informed consent of Continuation ECT and is educated concerning the risks and benefits.

Maintenance ECT - Medically Necessary Criteria

Must meet all of the following:

ALL of the following

The attending psychiatrist performs an assessment of current symptoms and medications.
The attending psychiatrist determines the need for Maintenance ECT.
The attending psychiatrist determines the timing and frequency of treatments.
The member has shown an adequate response to the continuation of ECT.
ONE of
- The member has a marked history of relapse and recurrence.

Provider Actions & Submission Requirements

Documentation Required

Complete member and clinical information on form

All member identifying fields must be completed on the form or it will be returned. Type or print neatly and complete all applicable fields; include the member's name, date of birth, insurance ID number, and phone number. Also provide numerical diagnosis code(s) from the DSM-5 or ICD-10 as requested on the form.

Member's Name
Date of Birth
Insurance ID Number
Member's Phone Number
Numerical diagnosis code(s) (DSM-5 or ICD-10)

Prior Authorization

Authorization submission for continuation/maintenance ECT

Use this form to request continuation or maintenance outpatient ECT. Return the completed form via fax to the appropriate fax number for the member's plan.

Lucet Employee: 816-416-7788
Internal Behavioral Health Benefit Review: 816-237-2364

Billing Rule

Units allowed for Continuation and Maintenance

For ECT requests determined to be medically necessary, the following unit limits apply for the associated CPT codes.

00901 (Electroconvulsive Therapy Facility): Continuation ECT — 6 units per 6 months
90870 (Electroconvulsive Therapy Treatment and Monitoring): Maintenance ECT — 24 units per 1 year

Documentation Required

Clinical attestation checkbox

The attending psychiatrist must check the attestation box on the form affirming that all information provided is accurate and is reflected in the patient's medical record.

Background

This form applies only to continuation and maintenance outpatient ECT treatment and summarizes the medical necessity criteria and submission instructions. It lists the required clinician assessments (attending psychiatrist assessment of current symptoms and medications; determination of need, timing, and frequency), patient response or intolerance criteria, consent requirements, and billing codes/units. Complete all member identifying fields (name, DOB, insurance ID, phone) or the form will be returned; type or print neatly and include numerical diagnosis codes. Return the completed form via fax to the appropriate number for the member's plan (e.g., Lucet Employee 816-416-7788 or Internal Behavioral Health Benefit Review 816-237-2364). For full medical policy information, see Lucethealth.com under Medical Necessity Criteria.