Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthLucet ECT Coverage Prior Auth Policy Update | Open…
    Ask Trek AI about this page
    CurrentlucetPolicy 20.5.002

    Electroconvulsive Therapy (ECT) — Coverage Criteria

    Customize your policy alerts

    Sign up for lucet Policy 20.5.002 alerts

    Get alerted when Policy 20.5.002 changes without checking for updates manually.

    Monitor payer policy activity

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

    Policy governing medical necessity, authorization criteria, and expectations for ECT (initial, continuation, and maintenance) for members whose benefits include ECT; applies to providers requesting coverage.

    Policy Summary
    Payerlucet
    PolicyElectroconvulsive Therapy (ECT) — Coverage Criteria
    Policy CodePolicy 20.5.002
    Change TypeNo material change
    Effective DateAug 1, 2021
    Last ReviewSep 1, 2025
    Next Review Date
    Key ActionObtain prior authorization documenting that initial authorization criteria are met to approve twelve (12) units of CPT 90870.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12Initial approval CPT units authorized (90870)
    6–12Typical total number of treatments in a series
    3× weeklyTypical frequency of initial ECT treatments
    13+FDA clearance age

    Coverage and Medical Necessity Criteria

    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.

    Initial and Continuation Authorization Criteria

    Initial Authorization Requirements — ECT is medically necessary for approval of 12 units of CPT 90870 when ALL of the following are met:

    Initial Authorization

    • Primary DSM diagnoses

      • Major Depressive Disorder: single or recurrent; severe, psychotic, or non-psychotic
      • Bipolar Disorder: depressed, mixed, manic
      • Schizophrenia/Schizoaffective/Schizophrenia Spectrum/Psychotic Disorders: Schizophrenia/Schizophrenia Spectrum/Schizoaffective/Psychotic Disorders
      • Catatonia
      • Neuroleptic Malignant Syndrome
    • Expectation of benefit: There is a reasonable expectation of reduction in the severity of the current condition and behaviors with ECT.
    • Diagnostic evaluation: A complete diagnostic psychiatric evaluation is completed prior to initiation of ECT.

    • Prior treatments or conditions

      • Medication trials/augmentation or intolerance: Documentation of two or more adequate trials of full-dose antidepressants (adequate time = 8 weeks). Augmentation with lithium, thyroid or atypical antipsychotics has been tried or considered, or inability to tolerate medication due to serious side effects.
      • Marked impairment: Member is markedly impaired by psychiatric illness with likely serious physiologic or physical complications.
      • Prior ECT response: History of a significant prior response to ECT.
    • Informed consent: The member or guardian provides informed consent of ECT and is educated concerning the risks and benefits.

    Expectations of Care Delivery

    Expectations of Care Delivery — requirements for providers and settings

    Care Delivery Expectations

    • Qualified attending physician: Primary attending physician is a psychiatrist trained and credentialed to administer ECT; responsible for diagnostic evaluation and provides face-to-face services with documentation.
    • State law compliance: Provider and facility must meet all applicable state laws and regulations regarding the practice of ECT.
    • Family/support education: Family/support system is educated about ECT practice, post-discharge care, activity restrictions, and likely need for outpatient continuation including transportation considerations.
    • Age and consent considerations: FDA has approved ECT devices for individuals 13 and older; special informed consent attention for adolescents; no upper age limit; comply with state-specific regulations.

    Services are eligible for coverage only when benefits are available in the member's contract or certificate and the service meets the policy's medical necessity criteria. If the member’s benefit plan does not include coverage for ECT, the service is excluded from coverage regardless of clinical indications.

    Billing and Coding

    Covered CPT CodesCPTCovered
    90870Electroconvulsive therapy (includes monitoring)

    Provider Requirements and Authorization Steps

    Prior Authorization

    Prior authorization required for initial ECT (CPT 90870)

    Initial authorization is required for approval of twelve (12) units of CPT code 90870. Requests must meet the Initial Authorization Requirements before coverage will be approved.

    • Authorization is for 12 units of CPT 90870 when criteria are met.
    Step Therapy

    Document medication trials before initiating ECT for depressive indications

    For most depressive indications, the request must document two or more adequate trials of full‑dose antidepressants (adequate time = eight (8) weeks) with augmentation tried or considered, unless there is intolerance or other alternative criteria.

    • Adequate trials defined as full‑dose antidepressant therapy for eight (8) weeks.
    • Augmentation with lithium, thyroid, or atypical antipsychotics should have been tried or considered.
    • Alternative: inability to tolerate medication due to serious side effects, marked impairment with likely serious physiologic complications, or history of significant prior ECT response.
    Documentation Required

    Required documentation: evaluation, consent, attending psychiatrist notes, and forms

    Include a complete diagnostic psychiatric evaluation, documentation of informed consent and education about risks/benefits, and attending psychiatrist face‑to‑face documentation of assessment and treatment planning; use the specified outpatient ECT request forms where applicable.

    • Complete diagnostic psychiatric evaluation completed prior to initiation of ECT.
    • Member or guardian provides informed consent and is educated concerning risks and benefits.
    • Attending psychiatrist is trained and credentialed, provides face‑to‑face services with documentation and is responsible for diagnostic evaluation.
    • Use the Initial Outpatient ECT Treatment Request Form or Continuation/Maintenance Outpatient ECT Request Form as applicable.
    Denial Risk

    Confirm member benefits and obtain CMO approval for exceptions

    Coverage is available only if the member’s contract/certificate includes benefits for ECT and the medical necessity criteria are met; any exception to this policy must be approved by the Chief Medical Officer or their designee.

    • Verify that ECT benefits exist in the member’s contract/certificate before requesting authorization.
    • Submit exception requests to the Chief Medical Officer (CMO) or designee for approval.

    Clinical Background

    Electroconvulsive therapy (ECT) involves inducing a therapeutic seizure via a transcranial electrical stimulus and is used for severe mood disorders, psychotic disorders, catatonia, neuroleptic malignant syndrome, and other conditions when a rapid clinical response is needed or when other treatments have failed. Treatment is delivered in phases: an initial (index) series to achieve acute response, a Continuation phase (up to six months) to prevent relapse, and Maintenance ECT beyond six months to prevent recurrence, with frequency tapered as clinically indicated. Typical initial treatment frequency is three times weekly, and the usual total number of treatments in an index series is about 6–12 treatments.

    Key Definitions

    Continuation ECT — definition and practice
    DefinitionECT provided after the index series for up to six months to individuals in remission intended to prevent relapse; typically administered outpatient with frequency tapering from weekly to monthly.
    Typical settingGenerally provided on an outpatient basis; may follow inpatient index series.
    Typical frequencyStarts about weekly and gradually reduces to monthly or longer as clinically stable.
    IntentPrimarily to prevent relapse following successful index (acute) ECT series.
    Evidence noteMedical literature is limited regarding efficacy, but relapse rates after index course are substantial.
    Maintenance ECT — definition and practice
    DefinitionECT delivered prophylactically after the six-month continuation period to prevent recurrence; almost exclusively outpatient with frequency based on clinical need.
    Typical settingAlmost exclusively provided as an outpatient service.
    Frequency determinationTreatment frequency depends on what is required to prevent recurrence; no standard optimal duration established.
    IntentProphylactic prevention of recurrence beyond the continuation phase.
    Evidence noteLimited medical literature evidence for efficacy and no evidence on duration of maintenance ECT.

    Settings and Level of Care

    Inpatient / Outpatient / Residential (occasionally)

    Appropriate level of care for ECT delivery

    Appropriate settings: ECT is typically administered at inpatient or outpatient facility level of care; in certain circumstances, may be appropriate for Residential level of care though treatment would likely be rendered at an outpatient facility.

    Treatment Modalities and Indications

    ECT — treatment modality

    ECT — treatment phases and modality-specific expectations

    Treatment phases: Initial (index) series, Continuation (up to 6 months), Maintenance (beyond 6 months) with differing intents: acute response, relapse prevention, and recurrence prevention respectively.

    Visit and Unit Limits

    CPT 90870 — visit limit
    CPT code90870 — Electroconvulsive therapy (includes monitoring)
    Authorized units (initial)12 units authorized when Initial Authorization Requirements are met.
    Use contextApplied for initial authorization of an index ECT series per policy criteria.
    Billing noteInitial authorization requires documentation meeting the policy's Initial Authorization Requirements.
    Policy Summary
    Payerlucet
    PolicyElectroconvulsive Therapy (ECT) — Coverage Criteria
    Policy CodePolicy 20.5.002
    Change TypeNo material change
    Effective DateAug 1, 2021
    Last ReviewSep 1, 2025
    Next Review Date
    Key ActionObtain prior authorization documenting that initial authorization criteria are met to approve twelve (12) units of CPT 90870.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaBilling and CodingProvider Requirements and Authorization StepsClinical BackgroundKey DefinitionsSettings and Level of CareTreatment Modalities and IndicationsVisit and Unit Limits
  1. Setting and treatment number: ECT is typically administered inpatient or outpatient; in certain circumstances Residential level may be appropriate though treatment likely rendered at an outpatient facility. Total number in a series is typically 6 to 12, dictated by clinical situation.