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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral Healthmediviewcurative ECT Coverage & Prior Auth Policy …
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    CurrentmediviewcurativePolicy MM-PNP-036

    Electroconvulsive Therapy (ECT) Coverage Criteria

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    Policy governing review, approval, and coverage criteria for Electroconvulsive Therapy (ECT), including required consent and limits on initial and subsequent treatment sessions for members under Curative Health Plan; references Texas law for consent requirements.

    Policy Summary
    Payermediviewcurative
    PolicyElectroconvulsive Therapy (ECT) Coverage Criteria
    Policy CodePolicy MM-PNP-036
    Change TypeNo material change
    Effective DateNov 1, 2023
    Next Review Date
    Key ActionObtain prior authorization and submit required Texas SB 800–compliant consent form; initial approvals limited to ≤6 sessions and subsequent approvals in increments of 3 with documentation of benefit.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≤6initial approved ECT sessions
    3subsequent session increments
    20series maximum treatments
    Appendix Aconsent form

    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.

    multiple/ultrabrief
    experimental techniques listed

    Coverage Criteria for ECT

    Initial ECT coverage criteria

    Covered when ALL of the following are met

    Medical necessity for ECT: Member has a qualifying diagnosis: catatonia; certain acute schizophrenic exacerbations; major depressive disorder (unipolar); bipolar disorder; or mania.

    chunk 5

    Consent documentation: A consent form meeting the requirements of the Texas Mental Health Code / SB 800 must be completed and submitted with each ECT request (see Appendix A).

    chunk 5

    Initial treatment limit: Initial approval limited to no more than six ECT sessions.<=6 sessions

    chunk 4

    Continuation and maximum series criteria

    Continuation/extension covered when ALL of the following are met

    Demonstrated benefit: Documented positive member response to prior ECT treatments is required for subsequent approvals and continued medical necessity.

    chunk 5

    Subsequent approval increments: Subsequent requests will be approved in increments of three treatments when ongoing medical necessity is demonstrated.increments of 3

    chunk 4

    Series maximum: Total treatments in a treatment series must not exceed 20 except in rare circumstances; additional, less frequent prophylactic sessions may be considered indefinitely.<=20 in a series (rarely exceeded)

    chunks 4 and 5

    Curative considers several electroconvulsive therapy (ECT) techniques and adjuncts to be experimental or investigational because their effectiveness has not been established. These include multiple monitored ECT (MMECT), ultrabrief bilateral ECT, and the use of adjunctive ketamine in ECT. Requests for coverage of these specific techniques or adjunctive approaches will be denied as investigational.

    ECT is considered investigational for a range of diagnostic indications where evidence is insufficient to support routine use. The policy specifically lists ECT for addictive disorders (e.g., methamphetamine dependence), autism spectrum disorders, autoimmune encephalitis (for example anti‑NMDA receptor encephalitis), body dysmorphic disorder, complex regional pain syndrome, delirium, dementia‑associated agitation and aggression, drug‑resistant epilepsy, eating disorders, Lennox‑Gastaut syndrome, Parkinson disease motor symptoms, neuropsychiatric complications of COVID‑19, obsessive‑compulsive disorder, post‑traumatic stress disorder, refractory status epilepticus, self‑injurious behaviors, somatic symptom disorder, tardive dyskinesias/tardive syndromes, Tourette syndrome (tic disorders), and treatment‑resistant schizophrenia. The policy also identifies investigational use for various diagnostic tests and pharmacologic adjuncts related to ECT (for example certain functional MRI predictors, plasma BDNF measurement, and use of ketamine, liothyronine, melatonin, opioid receptor agonists, piracetam, or prophylactic cognitive enhancers). Coverage for ECT in these listed indications or for these investigational tests/adjuncts is considered not medically necessary.

    Provider Requirements and Authorization

    Prior Authorization

    Prior authorization required; session limits (initial ≤6, subsequent increments of 3)

    Prior authorization is required for ECT. Initial approvals will be for no more than six sessions; subsequent requests that meet medical necessity and document a positive member response will be approved in increments of three treatments up to a 20-treatment series maximum.

    • Initial approval: ≤ 6 ECT sessions
    • Subsequent approvals: increments of 3 treatments with documented medical necessity and positive response
    • Series maximum: generally ≤ 20 treatments (rarely exceeded)
    Step Therapy

    Clinical sequencing: when to use ECT in treatment course

    ECT is generally considered after medication failure, intolerability, or when medications are dangerous; it may be used first-line for severely ill patients needing a rapid response (e.g., high suicide/homicide risk, psychosis, stupor).

    Inpatient and Outpatient ECT Criteria

    ECT Treatment Modalities

    ECT — treatment modalities criteria

    ECT indications: Covered for catatonia, certain acute schizophrenic exacerbations, major depressive disorder (unipolar), bipolar disorder, and mania.

    chunk 5

    ECT experimental techniques: Multiple monitored ECT, ultrabrief bilateral ECT, and adjunctive ketamine in ECT are considered experimental and investigational and are excluded from coverage.

    chunk 6

    ECT Session Limits

    ECT sessions — limits (Initial, increments, series max)
    Initial approved sessionsInitial approval limited to no more than 6 ECT sessions
    Subsequent approval incrementsSubsequent requests approved in increments of 3 treatments with documented medical necessity and positive response
    Series maximumTotal treatments in a treatment series must not exceed 20 (rarely exceeded); additional less frequent prophylactic sessions may continue indefinitely

    Background and Mechanism

    Electroconvulsive therapy (ECT) is the intentional induction of a generalized seizure in an anesthetized patient via administration of electrical impulses, typically performed by a psychiatrist with anesthesia support. Treatments are administered on a scheduled basis, commonly 2–3 times per week, though more frequent sessions (occasionally daily) may be used if tolerated in specific clinical situations. A typical acute course for depression often ranges from about six to twelve treatments, and most initial authorizations are limited to no more than six sessions with continuation authorized only when a documented positive clinical response and ongoing medical necessity are provided. Up to 20 treatments may be required in some series; beyond that, rare exceptions may be considered. ECT is performed under general anesthesia with brief electrical stimulation to induce a controlled seizure and is used primarily for severe mood disorders, catatonia, certain acute psychotic exacerbations, and mania when rapid symptom control is needed or when medications are ineffective or contraindicated.

    Definitions

    Electroconvulsive Therapy (ECT) — definition and typical details
    DefinitionIntentional induction of generalized seizures by administering electrical impulses to an anesthetized patient
    Typical performersUsually performed by a psychiatrist with anesthesiology support (psychiatrist and an anesthesiologist or anesthetist)
    Typical setting & frequencyGenerally administered inpatient but can be outpatient in facilities with treatment and recovery rooms; usually 2–3 times per week (occasionally daily if tolerated)
    Primary indicationsPrimary indication is major depressive disorder; also used for catatonia, certain acute schizophrenic exacerbations, bipolar disorder, and mania
    Multiple monitored ECT (MMECT) — definition and coverage stance
    Definition
    Policy Summary
    Payermediviewcurative
    PolicyElectroconvulsive Therapy (ECT) Coverage Criteria
    Policy CodePolicy MM-PNP-036
    Change TypeNo material change
    Effective DateNov 1, 2023
    Next Review Date
    Key ActionObtain prior authorization and submit required Texas SB 800–compliant consent form; initial approvals limited to ≤6 sessions and subsequent approvals in increments of 3 with documentation of benefit.
    SourceLink
    On This Page
    Coverage Criteria for ECTProvider Requirements and AuthorizationInpatient and Outpatient ECT CriteriaECT Treatment ModalitiesECT Session LimitsBackground and MechanismDefinitions
  1. Consider ECT when medications fail, cannot be tolerated, or pose danger
  2. May be first-line for severe presentations requiring rapid response (high suicide/homicide risk, extreme agitation, life‑threatening inanition, psychosis, stupor)
    3. Documentation Required

    Submit Texas SB 800–compliant consent form with each request

    A consent form that meets the requirements of the Texas Mental Health Code / SB 800 must be completed and submitted with each ECT request; see Appendix A in the policy for the required consent form.

    • Submit the completed Texas Mental Health Code / SB 800–compliant consent form with every prior authorization request for ECT
    • Refer to Appendix A of the policy for the consent form
    Documentation Required

    Documentation required for continuation: show medical necessity and positive response

    Subsequent ECT requests must include documentation showing continued medical necessity and a documented positive member response to prior ECT treatments in order to be approved.

    • Provide objective documentation of clinical benefit from prior ECT sessions
    • Demonstrate ongoing medical necessity for additional treatments
    Denial Risk

    Denial risk if exceeding initial limits or series maximum without justification

    Requests that exceed the initial six approved sessions or that would result in more than 20 treatments in a series risk denial unless medical necessity and documented positive response are provided to justify additional treatments.

    • Requests >6 sessions without required documentation risk denial
    • Requests exceeding a 20‑treatment series will be denied unless rare medical necessity and justification are documented
    Note

    Requests for experimental/investigational ECT techniques or listed indications will be denied

    Interventions listed as experimental or investigational (e.g., multiple monitored ECT, ultrabrief bilateral ECT, adjunctive ketamine in ECT, and the listed indications) are considered non‑covered and such requests will be denied; follow the plan’s non‑coverage/denial workflow for these requests.

    • Do not request coverage for multiple monitored ECT, ultrabrief bilateral ECT, or adjunctive ketamine in ECT—these are experimental/investigational
    • ECT for the enumerated indications (e.g., OCD, eating disorders, dementia-associated agitation, PTSD, treatment‑resistant schizophrenia, etc.) is considered experimental/investigational and will be denied
    Procedure in which multiple seizures are induced during a single treatment session before the patient regains consciousness (multiple monitored ECT, MMECT)
    EffectivenessThe effectiveness of MMECT has not been established
    Policy stanceMMECT is considered experimental/investigational and will be denied under this policy