Electroconvulsive Therapy (ECT) - 2024
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Defines medical necessity, authorization, and clinical requirements for ECT benefit approval for Lucet members and providers during plan year 2024.
No material clinical or coverage changes in this revision.
Coverage Criteria for ECT
inv-01: Initial Authorization
Covered when ALL of the following are met
Acute treatment frequency typically 3–5 times/week
inv-02: Continued Authorization
Covered when ALL of the following are met
inv-03: Continuation ECT (up to 6 months)
Continuation refers to treatments after index series for up to 6 months to individuals in remission
inv-04: Maintenance ECT (post-continuation)
Maintenance ECT is prophylactic after the 6-month continuation period; limited evidence for duration/efficacy
Facility and attending requirements: The primary attending physician must be a psychiatrist who is trained and credentialed to administer ECT and is responsible for the diagnostic evaluation and face-to-face services with documentation. The attending and facility must meet all applicable state laws and regulations regarding the practice of ECT. The FDA has granted clearance for ECT devices for individuals aged 13 and older, and special attention to informed consent is required for adolescents. ECT is typically administered in an inpatient or outpatient facility; in some cases members at a Residential level of care may receive ECT rendered at an outpatient facility. The total number of treatments in an index series is typically 6–12, guided by the clinical situation.
Use beyond described indications or without meeting required documentation is not supported. Requests for ECT that do not meet the specified diagnostic indications (e.g., Major Depressive Disorder, Bipolar Disorder, Schizophrenia spectrum disorders, Catatonia, Neuroleptic Malignant Syndrome), lack a complete diagnostic psychiatric evaluation, fail to document required treatment history (such as two or more adequate trials of full‑dose antidepressants when indicated), are missing informed consent, or lack progress documentation as specified in the Continued Authorization requirements would be considered not medically necessary.
Continuation and maintenance uses also have defined requirements: Continuation ECT is limited to treatments after the index series for up to 6 months and requires attending assessment, documented adequate response to the index episode, and member preference or intolerance to pharmacotherapy. Maintenance ECT (post-continuation) requires attending assessment, demonstrated adequate response to continuation ECT, a marked history of relapse/recurrence (or symptom increase when tapering), member preference or intolerance to pharmacotherapy, and documented informed consent; uses outside these parameters are not supported.
CPT and Coding Details
| 90870 | ECT, general anesthesia |
Provider Requirements and Actions
Prior Authorization Required
Prior authorization required for initial ECT. Initial authorization is required for approval of twelve (12) units of CPT code 90870 and will be granted only when all clinical criteria for initiation are documented and met.
- Prior authorization required for initial ECT: approval of twelve (12) units of CPT 90870 when Initial Authorization Requirements are met
- Initial Authorization Requirements summary: DSM primary diagnosis (Major Depressive Disorder, Bipolar Disorder, Schizophrenia spectrum, Catatonia, or Neuroleptic Malignant Syndrome); reasonable expectation of benefit; complete diagnostic psychiatric evaluation prior to initiation; one of the following: two or more adequate trials of full‑dose antidepressants (adequate time = 8 weeks) with consideration/attempt of augmentation OR inability to tolerate medications OR marked impairment with high risk of serious complications OR history of significant prior response to ECT; typical acute frequency ~3–5 times/week (commonly 3/week); informed consent and education documented
- Provider must document informed consent/guardian consent and education on risks/benefits, post‑discharge care, activity restrictions, and transportation/continuation planning
- Attending physician must be a psychiatrist credentialed to administer ECT and must complete face‑to‑face diagnostic evaluation and maintain documentation
Denial Triggers
Triggers for denial. Requests may be denied if required documentation or criteria are missing or not met.
- Missing or incomplete diagnostic psychiatric evaluation or failure to document a qualifying DSM primary diagnosis
- No documentation of two or more adequate trials of full‑dose antidepressants (adequate trial = 8 weeks) when indicated, or lack of documented alternative indication (e.g., intolerance to medications, marked impairment, or prior significant ECT response)
- Absence of documented informed consent (member or guardian) and education regarding risks, benefits, and post‑discharge care
- Attending physician not identified as a psychiatrist trained/credentialed to administer ECT or lack of face‑to‑face evaluation documentation
- For continuation requests: lack of documentation of progress toward objective, measurable treatment goals, lack of evidence of improvement or timely re‑evaluation and treatment plan modifications when condition not improving
Background on ECT
Electroconvulsive Therapy (ECT) is a medical treatment that uses transcranial electrical stimulation to induce a therapeutic seizure with the intent of producing acute and prolonged neurophysiologic changes to improve symptoms of certain psychiatric conditions. It is indicated for disorders including Major Depressive Disorder, Bipolar Disorder, schizophrenia spectrum and other psychotic disorders, catatonia, and Neuroleptic Malignant Syndrome, particularly when rapid benefit is needed, prior treatments have failed, or there is marked impairment.
ECT is typically delivered under general anesthesia by a psychiatrist trained in ECT and administered in inpatient or outpatient settings. Modern techniques and anesthesia have improved safety and tolerability; the FDA has cleared ECT devices for use in individuals aged 13 and older. An index ECT series commonly includes 6–12 treatments, usually given about 3–5 times per week during the acute course, with continuation treatment available for up to 6 months to prevent relapse and maintenance treatment thereafter in selected patients.
Key Definitions
Setting and Level-of-Care Considerations
Treatment Modalities
inv-16: ECT — treatment modality node
Visit Limits and Quantity Rules
Policy Revision History
Policy originally became effective on 08/21 (Original Effective Date).
Revision to the policy recorded on 09/22 (Revision Dates).
Policy review documented on 11/21 (Review Dates).
Most recent documented policy review occurred on 09/23 (Review Dates / last review).
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