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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthLucet outpatient ECT Coverage & Prior Auth | OpenP…
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    CurrentlucetPolicy N/A

    REQUEST FOR CONTINUATION OR MAINTENANCE OUTPATIENT ELECTROCONVULSIVE THERAPY (ECT)

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    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

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    2
    Unit 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.

    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

    Billing Codes

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

    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.

    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.

    Revision History

    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
    On This Page
    Coverage SummaryMedically Necessary CriteriaBilling CodesProvider Actions & Submission RequirementsBackgroundRevision History
    The member expresses a preference to continuation ECT.
  1. The member is intolerant to pharmacotherapy.
  2. The member or guardian provides informed consent of Continuation ECT and is educated concerning the risks and benefits.

    3. 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.
      • The member has a history of significant symptom increases when Continuation ECT was tapered.

    • ONE of

      • The member expresses a preference for Maintenance ECT.
      • The member is intolerant to pharmacotherapy.
    • The member or guardian provides informed consent of Maintenance ECT and is educated concerning the risks and benefits.
    • 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.