CurrentlucetPolicy N/A

Electroconvulsive Therapy (ECT) authorization form / coverage criteria

This document is a provider-facing form and guidance governing authorization and submission requirements for ECT services for Lucet members; it affects ordering clinicians, facilities, and utilization reviewers who request coverage or verification for ECT.

Policy Summary

Payerlucet

PolicyElectroconvulsive Therapy (ECT) authorization form / coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the ECT authorization form with required member, provider, facility, diagnosis, treatment history attestation, and clinical documentation to verify medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

00901, 90870CPT codes referenced for ECT

12Initial ECT units suggested

WebPass + FaxSubmission channels

NC? (not specified)Applicable state(s) listed

Coverage Criteria and Authorization Rules

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Initial ECT criteria

Covered when AT LEAST ONE of the following attested criteria is met and properly documented in the medical record:

ECT eligibility attestation: One or more of: two or more adequate trials of full dose antidepressants (adequate time = eight (8) weeks); augmentation with lithium, thyroid, or atypical antipsychotics tried or considered; inability to tolerate medication due to severe or intolerable side effects; marked impairment with high likelihood of physiological/physical complications; history of significant positive prior response to ECT.at least 1 box checked

Documentation of trials and clinical rationale required

Authorization is not required for the following BCBS products as listed on the form: BCBS Alabama (except Lowe's), BCBS Arkansas (except for FEP), BCBS Kansas, and Walmart. For verification of benefits, eligibility, authorization requirements, and allowable codes, providers must contact the customer service number on the member's insurance ID card or use the resources referenced by Lucet.

The form notes that incomplete forms cannot be processed. All required fields (indicated by an asterisk) must be completed; missing required information may result in a delay, denial, or inability to determine medical necessity.

Procedure and Coding Information

Covered CPT Codes referenced on formCPTCovered

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

inv-05: Adequate antidepressant trial duration — specified as 8 weeks on the form

Adequate antidepressant trial durationAdequate time defined as eight (8) weeks for a full‑dose antidepressant trial

Trial count for attestationTwo or more adequate trials of full‑dose antidepressants required as one eligible criterion

Context of useListed as an attestation checkbox on the ECT request form to support medical necessity

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization and CPT Codes

Authorization requirements and applicable CPT codes vary by local BCBS product. Verify benefits, eligibility, and whether prior authorization is required via WebPass (https://webpass.ndbh.com/) or by fax per payer instructions. For Lucet employees (Blue KC), fax to 816-416-7788. General fax for submissions: 816-237-2364 (unless otherwise noted). For ECT found medically necessary, expected CPT codes/units include: 00901 (Electroconvulsive Therapy Facility) and 90870 (Electroconvulsive Therapy Treatment and Monitoring). ECT initial authorization typically: 12 units / 8 weeks. Note: call the customer service number on the member's ID card for benefits/authorization specifics.

WebPass: https://webpass.ndbh.com/
Fax: 816-237-2364 (All except Blue KC Lucet Employee Group)
Lucet Employees (Blue KC) fax: 816-416-7788
Covered/authorization-exempt examples: BCBS Alabama (Except Lowe's), BCBS Arkansas (Except FEP), BCBS Kansas, Walmart — verify specific product rules

Denial Risk

Incomplete Submission Risk

Incomplete or illegible submissions cannot be processed. Complete all required fields (indicated by *), type or print neatly, and mark sections that are not applicable. Incomplete forms will delay or prevent authorization determination.

Complete all required fields (indicated by *)
Mark nonapplicable sections explicitly
Write DSM-5 or ICD-10 diagnosis codes as required
Incomplete forms cannot be processed

Documentation Required

Required Documentation on Form

Provide a completed form with all required documentation: member information (name, insurance policy #, DOB, phone), requesting physician information (name, phone, address where services rendered, Tax ID, NPI), facility information (name, phone, address where services rendered, Tax ID, NPI), and utilization reviewer contact info (name, fax, phone). Include clinical history, current episode duration, primary diagnoses with DSM-5/ICD-10 codes, and current symptoms/relevant clinical information.

Member's Information: Name*, Insurance Policy #*, DOB*, Phone #
Requesting Physician: Name*, Phone*, Address*, Tax ID*, NPI*
Facility: Name*, Phone*, Address*, Tax ID*, NPI*
Utilization Reviewer Contact: Name*, Fax*, Phone*
Clinical history: Primary diagnoses with DSM-5/ICD-10 codes, current episode duration, current symptoms

Documentation Required

Required Treatment History Attestation

The provider must attest that the member has met one or more required treatment history conditions before ECT is considered: at least two adequate trials of full-dose antidepressants (adequate time = 8 weeks), or augmentation with lithium/thyroid/atypical antipsychotics tried or considered, or inability to tolerate medication due to severe side effects, or marked impairment with high risk of physiological/physical complications, or history of significant positive prior response to ECT. A checkbox attestation confirming accuracy of the information and that it is reflected in the patient's medical record is required.

At least two adequate trials of full-dose antidepressants (≥ 8 weeks)
Augmentation with lithium, thyroid, or atypical antipsychotic tried or considered
Inability to tolerate medication due to severe/intolerable side effects
Marked impairment with high risk of physiological/physical complications
History of significant positive prior response to ECT
Provider must check attestation box confirming accuracy and medical record documentation

Clinical Background

Electroconvulsive therapy (ECT) is indicated for severe or treatment-resistant psychiatric conditions. The form requests the member's primary diagnosis (DSM-5 or ICD-10) and asks the provider to document the clinical rationale for ECT, including prior treatment history (e.g., adequate medication trials, augmentation attempts, intolerance, marked impairment, or prior positive response to ECT) to support medical necessity.

Key Definitions

inv-11: Adequate medication trial — definition/usage as referenced on the form

Definition on formAn 'adequate medication trial' is used in the form to mean a full‑dose antidepressant taken for the adequate time of eight (8) weeks

Usage in attestationThe form asks providers to attest that two or more adequate trials of full‑dose antidepressants (each ≥8 weeks) have been tried

PurposeUsed to document prior treatment history to demonstrate failure of or intolerance to medications before ECT is authorized

Service-Level Criteria

ECT service (procedure-level)

Procedure-level criteria and documentation requirements for ECT service billing and continued delivery:

Procedure-level documentation: Primary diagnosis (DSM-5 or ICD-10) must be provided and documented; ECT start date and current episode duration must be recorded.diagnosis provided

Document DSM-5 or ICD-10 code on form

CPT coding and initial units: For ECT requests found to be medically necessary, use CPT codes 00901 (Electroconvulsive Therapy Facility) and 90870 (Electroconvulsive Therapy Treatment and Monitoring) as applicable. Initial course: 12 units over 8 weeks.12 units/8 weeks

Apply facility and psychiatrist codes as appropriate

Submission completeness: The form must be completed in its entirety; sections not applicable must be marked as such to ensure timely processing.complete form

Incomplete submissions may delay or prevent authorization

Treatment Modalities

ECT — treatment modality criteria

ECT treatment parameters: Initial ECT course referenced as 12 units over 8 weeks; document continued clinical response and number of ECT units delivered as appropriate.12 units/8 weeks

Ongoing justification and clinical response must be recorded in the medical record

Limits and Suggested Units

inv-14: ECT initial units — suggested initial units on the form (12)

Initial ECT units recommendedECT Initial: 12 units over an 8‑week period

Associated CPT codes00901 (facility) and 90870 (psychiatrist) to be used as applicable with initial units

Documentation requirementOngoing documentation of number of ECT units delivered and clinical response expected in the medical record