CurrentlucetPolicy 20.5.002

Electroconvulsive Therapy (ECT)

Policy governing medical necessity, authorization, and coverage criteria for initial, continuation, and maintenance electroconvulsive therapy (ECT) for members whose benefits include ECT.

Policy Summary

Payerlucet

PolicyElectroconvulsive Therapy (ECT)

Policy CodePolicy 20.5.002

Change TypeNon-material updates (references, summary of evidence)

Effective Date08/2021

Next Review Date

Key ActionObtain prior authorization meeting Initial Authorization Requirements to approve twelve (12) units of CPT code 90870.

SourceLink

POLICY UPDATE CHANGES

Updated 1 reference and removed 3 references; updated Summary of Evidence.

Added description of treatment and summary of evidence and added 5 references; reorganized for clarity.

6-12typical total number of ECT treatments in a series

12CPT 90870 initial authorization approved amount

3x/wktypical frequency of initial ECT treatments

13+FDA-cleared minimum age for ECT devices

NCexplicitly applicable state

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Coverage and Medical Necessity Criteria

Medical Necessity Criteria (Initial, Continuation, Maintenance)

Covered when ALL of the following are met for the relevant phase

Continuation Authorization Requirements

Acceptable diagnoses for continuation: Major Depressive Disorder; Bipolar Disorder; Schizophrenia/Schizophrenia Spectrum/Schizoaffective/Psychotic Disorders; Catatonia; Neuroleptic Malignant Syndrome
Treatment compliance and expectation: Compliance with treatment plan (unless clinically precluded); reasonable expectation of improvement with continued ECT.
Objective progress documentation: Documentation of progress toward objective, measurable treatment goals required for continuation; if not progressing or worsening, evidence of timely reevaluation and treatment plan modifications.

Continuation ECT specific requests

Attending psychiatrist responsibilities: Attending psychiatrist must assess current symptoms and medications, determine need for continuation ECT, and determine timing and frequency.
Response and preference: Member has shown adequate response to index ECT; member prefers continuation ECT OR is intolerant to pharmacotherapy; informed consent documented.

Maintenance ECT specific requests

Attending psychiatrist responsibilities for maintenance: Attending psychiatrist must assess current symptoms and medications, determine need for maintenance ECT, and determine timing and frequency of treatments.
Response, history, and preference: Member has shown adequate response to continuation ECT; 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 documented.

Expectations of care delivery

Provider and facility requirements: Primary attending physician is a psychiatrist trained and credentialed to administer ECT; meets state laws and regulations; face-to-face evaluation and documentation required.
Care coordination and limits: Family/support system education, attention to post-discharge care and transportation; FDA-cleared for devices for ages 13+; typical total number of treatments in a series is 6–12 and frequency of initial treatments typically three times weekly.

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

Services are eligible for coverage only when benefits are available in the member's contract/certificate and all applicable medical necessity criteria and guidelines are met. Services that do not meet the stated benefits, fail to meet the medical necessity criteria (for example, diagnostic criteria, required medication trials, or informed consent), or lack required documentation (such as a complete diagnostic psychiatric evaluation or documentation of medication trials) are not eligible for coverage.

Billing and Coding

Covered CPT Codes (initial authorization)CPTCovered

90870

Electroconvulsive therapy (including anesthesia) (from document)

Adequate antidepressant trial duration — 8 weeks

Adequate trial durationEight (8) weeks

Required trialsDocumentation of two or more adequate trials of full‑dose antidepressants (with augmentation tried or considered) or documented intolerance to medications

Context in criteriaThis duration is the definition of 'adequate time' for initial authorization medication trials per Initial Authorization Requirements

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required for Initial ECT

Initial authorization is required for initiation of ECT. Initial authorization supports approval of up to twelve (12) units of CPT code 90870 when the Initial Authorization Requirements are met (diagnosis, expectation of benefit, completed diagnostic psychiatric evaluation, medication-trial or alternative criteria, and informed consent). Requests must include documentation of the diagnostic evaluation and the attending psychiatrist’s face-to-face assessment.

Affected code: CPT 90870 — initial authorization supports twelve (12) units
Documentation required at submission: complete diagnostic psychiatric evaluation; face-to-face documentation by the attending psychiatrist
Medication trial requirement: documentation of two or more adequate trials of full-dose antidepressants (adequate time = 8 weeks) OR inability to tolerate medications OR marked functional impairment with high risk of physiological/physical complications OR prior significant positive response to ECT

Denial Risk

Background and Clinical Context

Electroconvulsive therapy (ECT) induces a therapeutic seizure via transcranial electrical stimulation and is used for severe mood disorders, psychosis, catatonia, and neuroleptic malignant syndrome. ECT treatment is delivered in phases: an index (acute) series, a continuation phase (up to six months to prevent relapse), and maintenance therapy thereafter to prevent recurrence. Initial ECT is typically administered at a frequency of about 3 times per week during the acute series; documentation requirements before initiation include a complete diagnostic psychiatric evaluation and informed consent.

Key Definitions

Continuation ECT — treatments after the index series for up to six months for individuals in remission, typically outpatient and decreasin...

DefinitionContinuation ECT: treatments after the index series for up to six (6) months for individuals in remission

Typical settingGenerally administered on an outpatient basis

Frequency patternTypically begins weekly then gradually decreases to monthly or longer as member remains clinically stable

PurposeConceptually designed to prevent relapse after the index course

Maintenance ECT — prophylactic ECT after the six-month continuation period to prevent recurrence; frequency individualized and duration un...

DefinitionMaintenance ECT: prophylactic ECT delivered after the six (6) month continuation period to prevent recurrence

Settings: Inpatient, Outpatient, Residential

Electroconvulsive Therapy (ECT) Treatment Details

ECT

ECT modality: ECT used for major depression, bipolar disorder, schizophrenia/psychotic disorders, catatonia, neuroleptic malignant syndrome and in urgent situations (e.g., suicidality); frequency and phases (index, continuation, maintenance) described.

Visit and Unit Limits

CPT 90870 — 12 units (initial authorization)

CPT code90870 — Electroconvulsive therapy (including anesthesia)

Initial authorization amountTwelve (12) units approved when Initial Authorization Requirements are met

Associated requirementInitial authorization approval of 12 units is contingent on meeting all Initial Authorization Requirements (diagnosis, evaluation, medication trials or alternatives, informed consent)