CurrentlucetPolicy 20.5.002

Electroconvulsive Therapy (ECT)

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Medical necessity and coverage criteria for initial, continuation, and maintenance electroconvulsive therapy (ECT) for members whose benefits include ECT. Applies to providers requesting authorization for ECT services.

Policy Summary

Payerlucet

PolicyElectroconvulsive Therapy (ECT)

Policy CodePolicy 20.5.002

Change TypeContent added and reorganized

Effective DateAug 1, 2021

Last ReviewSep 1, 2024

Next Review Date

Key ActionRequest initial authorization for twelve (12) units of CPT 90870 when initial authorization requirements are met, including diagnostic evaluation, medication trials or exceptions, and informed consent.

SourceLink

POLICY UPDATE CHANGES

Added description of treatment and summary of evidence; reorganized to improve clarity.

12initial approval units for CPT 90870

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CurrentlucetPolicy 20.5.002

Electroconvulsive Therapy (ECT)

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Policy Summary

Payerlucet

PolicyElectroconvulsive Therapy (ECT)

Policy CodePolicy 20.5.002

Change TypeContent added and reorganized

Effective DateAug 1, 2021

Last ReviewSep 1, 2024

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Added description of treatment and summary of evidence; reorganized to improve clarity.

12initial approval units for CPT 90870

Coverage Criteria for Electroconvulsive Therapy (ECT)

inv-01: Initial Therapy

Initial Authorization — Covered when ALL of the following are met:

Initial Authorization Requirements

A.i Diagnoses: Primary DSM diagnosis must be one of: Major Depressive Disorder (single or recurrent; severe, psychotic, or non-psychotic); Bipolar Disorder (depressed, mixed, manic); Schizophrenia/Schizophrenia Spectrum/Schizoaffective/Psychotic Disorders; Catatonia; Neuroleptic Malignant Syndrome
A.ii-iii: There is a reasonable expectation of reduction in the severity of the current condition and behaviors with ECT AND a complete diagnostic psychiatric evaluation is completed prior to initiation
A.iv Medication trial or exceptions: One of: (1) two or more adequate trials of full-dose antidepressants (adequate time = 8 weeks) with augmentation tried or considered; OR inability to tolerate medications due to serious side effects; OR (2) member is markedly impaired with likely serious physiological/physical complications; OR (3) history of significant prior response to ECT
Acute treatment frequency typically 3-5 times per week
A.v Consent: Member or guardian provides informed consent and is educated on risks and benefits

inv-02: Continuation Therapy

Continuation Authorization — Covered when ALL of the following are met:

Continuation ECT Requirements

B.a Diagnoses: Primary DSM diagnosis must be one of: Major Depressive Disorder; Bipolar Disorder; Schizophrenia/Schizophrenia Spectrum/Schizoaffective/Psychotic Disorders; Catatonia; Neuroleptic Malignant Syndrome
B.b-c: Compliance with all aspects of the treatment plan (unless clinically precluded) AND a reasonable expectation of improvement in the current condition and behaviors with continued ECT
B.d Progress documentation: Documentation of member progress toward objective, measurable treatment goals required; if not progressing, evidence of timely reevaluation and treatment plan modifications

inv-03: Continuation Request Requirements

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

Continuation Request Specifics: Attending psychiatrist must assess symptoms and medications, determine need and timing/frequency of continuation ECT; member must have shown an adequate response to the index episode of ECT; member prefers continuation ECT or is intolerant to pharmacotherapy; informed consent provided

inv-04: Maintenance Request Requirements

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

Maintenance Request Specifics: Attending psychiatrist must assess current symptoms and medications and determine need and timing/frequency of maintenance ECT; member must have shown adequate response to continuation ECT; member has marked history of relapse/recurrence OR history of significant symptom increases when continuation ECT was tapered; member prefers maintenance ECT or is intolerant to pharmacotherapy; informed consent provided

inv-05: Care Delivery

Expectations of Care Delivery — Conditions to be met during delivery:

Care Delivery Expectations: Attending must be a psychiatrist trained and credentialed to administer ECT and provide face-to-face diagnostic evaluation with documentation; care must meet state laws/regulations; family/support system educated regarding ECT and post-discharge care; FDA device guidance applies (use in individuals 13 and older) and state-specific regulations followed; ECT is typically administered inpatient or outpatient and occasionally in Residential level with treatment rendered at an outpatient facility; total treatments in a series typically 6-12 determined by clinical situation

Exceptions to this medical policy must be approved by the Chief Medical Officer or their designee.

Coding and Billing

Covered CPT CodesCPTCovered

90870

ECT with anesthesia

Initial authorization units

Initial authorization units12 units of CPT code 90870 are considered medically necessary for initial authorization when Initial Authorization Requirements are met

Service codeCPT 90870 (ECT with anesthesia)

Approval conditionApproval tied to meeting all Initial Authorization Requirements (diagnosis, evaluation, medication trials or exceptions, informed consent)

Provider Requirements and Authorization Actions

Prior Authorization

Initial authorization: CPT 90870 — 12 units

ECT is considered medically necessary for approval of twelve (12) units of CPT code 90870 when the Initial Authorization Requirements are met. Use the Initial Outpatient ECT Treatment Request Form for initial outpatient authorization requests.

Approval for 12 units of CPT 90870 requires meeting all Initial Authorization Requirements (A.i–A.v).
Submit the Initial Outpatient ECT Treatment Request Form for initial authorization.

Step Therapy

Medication trial requirement before initial ECT

Initial ECT initiation generally requires documentation of two or more adequate trials of full‑dose antidepressants (adequate time = eight (8) weeks) and that augmentation with lithium, thyroid, or atypical antipsychotics has been tried or considered, unless the member is intolerant to medications or other listed exceptions apply.

Document two or more adequate trials of full‑dose antidepressants (each adequate trial = 8 weeks).

Background

Electroconvulsive Therapy (ECT) is a procedure that induces a therapeutic seizure using a scalp-applied electrical stimulus under anesthesia and is used for severe mood disorders, psychosis, catatonia, and other serious psychiatric conditions. ECT has been refined since its development and is indicated when rapid clinical response is needed or when other treatments have failed or are not tolerated.

ECT is typically delivered as an acute treatment series with frequency commonly starting at three times per week (often 3–5 times weekly) until a satisfactory clinical response is achieved, with a typical index series totaling 6–12 treatments. After the index series, Continuation ECT refers to treatments provided for up to six months to prevent relapse (frequency often begins weekly then tapers), while Maintenance ECT refers to prophylactic treatments beyond six months individualized to the patient to prevent recurrence.

Care delivery expectations include that the primary attending physician be a psychiatrist trained and credentialed in ECT, compliance with applicable state laws and facility credentialing, education of the patient and family about risks and benefits, and adherence to device and safety guidance (including FDA-cleared age considerations).

Definitions — Continuation and Maintenance

Continuation ECT

DefinitionECT treatments provided after the index series for up to six (6) months to individuals in remission intended to prevent relapse; typically outpatient

Typical frequencyFrequency typically starts weekly and is gradually tapered (e.g., weekly to monthly) as clinically stable

PurposeConceptually designed to prevent relapse after an index course of ECT

Evidence noteMedical literature evidence on efficacy is limited, but relapse rates after the index course are substantial

Maintenance ECT

DefinitionECT delivered prophylactically after the six (6) month Continuation ECT period aimed at preventing recurrence; almost exclusively outpatient

Level of Care — Site Settings

Treatment Modalities

inv-17: ECT

Indications: ECT is used for Major Depression, Bipolar Disorder, Schizophrenia/spectrum disorders, Catatonia, Neuroleptic Malignant Syndrome, and when rapid response is required or other treatments have failed

Supported by cited evidence summaries

Visit Limits and Typical Treatment Series

CPT 90870

CPT code90870

Initial units12 units authorized for initial ECT when criteria are met

Service descriptionECT with anesthesia

ECT treatments

Typical series total6–12 treatments is the typical total number in an ECT series

DeterminationTotal number should be dictated by the clinical situation and the attending psychiatrist's judgement

Delivery settingTypically administered at inpatient or outpatient facility; may be appropriate in Residential level with outpatient delivery