CurrentlucetPolicy N/A

Request for Initial Outpatient Electroconvulsive Therapy (ECT)

Governs requests for initial outpatient ECT treatment and the documentation required from providers and facilities submitting authorization requests for eligible members.

Policy Summary

Payerlucet

PolicyRequest for Initial Outpatient Electroconvulsive Therapy (ECT)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed initial outpatient ECT request form including member demographics, provider/facility details (NPI/Tax ID), DSM-5/ICD-10 diagnosis codes, and attested treatment history to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12ECT Initial units specified

00901,90870CPT codes listed for ECT

≥2Antidepressant trial requirement

NCApplicable state

Coverage Criteria for Initial Outpatient ECT

Initial outpatient ECT

Covered when at least one of the following attested criteria is met and appropriate documentation is provided on the form:

Initial outpatient ECT eligibility

Adequate medication trials: Two or more adequate trials of full dose antidepressants have been triedadequate time = 8 weeks
Augmentation with lithium, thyroid, or atypical antipsychotics has been tried or considered
Medication intolerance: Member unable to tolerate medication due to severe or intolerable side effects

Policy Summary

Payerlucet

PolicyRequest for Initial Outpatient Electroconvulsive Therapy (ECT)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Marked impairment/physiologic risk: Member is markedly impaired by psychiatric illness such that serious physiological or physical complications are very likely

Prior positive ECT response: History of a significant positive prior response to ECT

The form identifies payer lines for which prior authorization is not required. Authorization is not required for the following: BCBS Alabama (except Lowe’s), BCBS Arkansas (except FEP), BCBS Kansas, and Walmart. Providers should confirm the member’s specific plan/line prior to submission because these exceptions affect whether the completed form must be sent for authorization processing.

The request form must be completed in its entirety before submission. If a section does not apply, it should be explicitly marked “not applicable” to ensure timely processing; incomplete member or clinical sections risk return or delay of the authorization request.

Coding and Related Criteria

Covered CPT CodesCPTCovered

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

Diagnosis codingmixed

DSM-5 / ICD-10

Provider must write the numerical diagnosis code(s) from the DSM-5 or ICD-10 for primary diagnoses listed on the form

inv-06: Adequate antidepressant trial duration

Adequate trial duration>= 8 weeks (adequate time = eight (8) weeks)

Medication trial countTwo or more adequate trials of full-dose antidepressants

Augmentation considerationAugmentation with lithium, thyroid, or atypical antipsychotics has been tried or considered

Medication intoleranceMember unable to tolerate medication due to severe or intolerable side effects

Provider Actions, Documentation & Authorization

Denial Risk

Incomplete or Missing Form Information

All member information (member's name, date of birth, insurance ID number, member's phone number) must be completed. If the form is incomplete or missing required member, physician, facility, or clinical information, the form will be returned and authorization may be delayed or denied. If a section is not applicable, mark it as such; do not leave blanks.

Complete member demographics: name, DOB, insurance/policy number, phone.
If any required field is missing the form will be returned for completion.
Mark non-applicable sections as N/A to avoid processing delays.

Documentation Required

Required Documentation on Form

The ECT authorization request form must include complete documentation for the member, requesting physician, and facility, plus all ECT clinical fields. Provide the following on the submitted form:

Member information: Name, Insurance Policy/ID #, Date of Birth, Phone number.
Requesting physician: Name, Phone number, Service address, Tax ID, NPI.
Facility: Name, Phone number, Service address, Tax ID, NPI.
ECT clinical fields: ECT start date; primary diagnosis and DSM-5/ICD-10 code(s); current episode duration; current symptoms/clinical narrative.
A signed attestation box confirming information is accurate and reflected in the medical record.

Prior Authorization

Prior Medication Trials / Augmentation

The form requires documentation that at least one of the following prior treatment/clinical criteria has been met before approval is considered. Check the applicable box(es) and include supporting clinical notes or medication history as evidence.

Two or more adequate trials of full-dose antidepressants (adequate trial = 8 weeks) for the current episode.
Augmentation with lithium, thyroid supplementation, or atypical antipsychotics has been tried or appropriately considered.
Documented inability to tolerate medications due to severe/intolerable side effects.
Evidence that the member is markedly impaired and at imminent risk of serious physiological or physical complications from their psychiatric illness.
History of a significant positive prior response to ECT.

Background

Electroconvulsive therapy (ECT) is indicated for severe or treatment-resistant psychiatric conditions. The form lists primary diagnoses for which ECT may be requested, including major depressive disorder (single or recurrent), bipolar disorder (depressive, manic, mixed, or unspecified phases), schizophrenia spectrum or other psychotic disorders, catatonia, and neuroleptic malignant syndrome. ECT is considered when patients have marked impairment, failed adequate medication trials or augmentation strategies, cannot tolerate medications, or have a prior significant positive response to ECT; providers must indicate the applicable clinical rationale on the form and supply supporting documentation.

Primary Diagnoses / Definitions

inv-12: Primary diagnoses listed

Major depressive disorderMajor Depressive Disorder: single or recurrent; severe, psychotic or non-psychotic

Bipolar disorderBipolar Disorder: depressed, mixed, or manic

Schizophrenia spectrum/psychotic disordersSchizophrenia / Schizophrenia Spectrum / Schizoaffective / Psychotic Disorders

CatatoniaCatatonia

Neuroleptic malignant syndromeNeuroleptic Malignant Syndrome

Level of Care — Outpatient

Outpatient

Admission for outpatient ECT: Patient has one of the listed primary diagnoses and at least one attested indication (see Initial outpatient ECT criteria set)

Course specification: Initial authorization defined as 12 units over 8 weeks; continued treatment requires further documentation per medical necessity criteria on lucethealth.com

Treatment Modalities — ECT

ECT

ECT modality: Electroconvulsive therapy indicated for listed diagnoses when criteria are met

Visit Limits / Units

inv-15: ECT Initial — visit/unit limit

Initial course limitECT Initial: 12 units over 8 weeks

ServiceECT Initial

Period8 weeks