Coverage Policies

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1. Electroconvulsive therapy (ECT—also known as electroshock therapy) involves giving electrical impulses to an anesthetized patient to intentionally induce seizures.  This is most commonly used to treat severe and/or treatment resistant depression but may also be used for catatonia or certain acute exacerbations of schizophrenia or mania. More than 20 sessions in a treatment series are rarely medically necessary.  
2. ECT requires pre-authorization to ensure medical necessity.

Medical Policy Statement:

Electroconvulsive therapy (ECT) requires pre-authorization and is considered medically necessary when:

1.    Confirmed diagnosis of severe major depressive disorder (single or recurrent) documented by standardized rating scales that reliably measure depressive symptoms; AND

2.    Resistance to treatment with psychopharmacologic agents as evidenced by a lack of clinically significant response as documented by standardized rating scales that reliably measure depressive symptoms, to combination and/or augmentation of at least three  different drug regimens from two different drug classes OR Inability to tolerate psychopharmacologic agents as evidenced by trials of four such agents, from at least two different agent classes, with distinct side effects;

3.    The average course of treatment for depression is 6 to 12 treatments, but some patients may require as many as 20 treatments

OR

1.    Manic episodes in which it is unsafe to wait until a medication becomes effective or is unresponsive/intolerant to medications or has responded well to ECT in the past;

2.    The number of ECT treatments reported to be effective for mania ranges from 8 to 20.

OR

1.    ECT may be effective for exacerbations of psychosis in Schizophrenia especially with catatonic symptoms and when there is a history of a prior favorable response to ECT. 

2.    Schizophrenia may require 17 or more ECT treatments.

OR

1.    A small number of ECT treatments often reverse catatonia, a nonspecific symptom that can occur in mood disorders, schizophrenia, cognitive disorders, and medical and neurological illnesses. 

2.    Up to 12 treatments may be required in some patients.

Clinical documentation of the above treatment failures covering the previous 18 months of treatment must be submitted along with the prior authorization request for TMS. 

00104           Anesthesia for electroconvulsive therapy does not require pre-authorization when used with approved ECT.

Codes Used In This BI:

00170             Anesthesia for electroconvulsive therapy

90870             Electroconvulsive therapy (includes necessary monitoring)

The following uses of ECT are considered experimental/investigation and are therefore not covered (not an all-inclusive list):

·         Addictive disorders (e.g., methamphetamine dependence)

·         Autism spectrum disorders

·         Autoimmune encephalitis (e.g., anti-N-methyl-D-aspartate (NMDA) receptor encephalitis)

·         Body dysmorphic disorder

·         Complex regional pain syndrome

·         Dementia-associated agitation and aggression

·         Drug-resistant epilepsy

·         Eating disorders

·         Lennox-Gastaut syndrome

·         Obsessive-compulsive disorder

·         Post-traumatic stress disorder

·         Refractory status epilepticus

·         Self-injurious behaviors

·         Somatic symptom disorder

·         Tardive dyskinesias

·         Tourette syndrome (tic disorders)

·         Treatment-resistant schizophrenia

·         Multiple monitored ECT

·         Ultrabrief bilateral ECT

·         ECT with adjunctive ketamine

·         ECT with functional MRI (fMRI) to predict ECT outcome

·         ECT with measurement of Brain-derived neurotrophic factor (BDNF) to measure treatment response

·         ECT with prophylactic use of cognitive enhancers (such as cholinesterase inhibitors and Memantine)

Electroconvulsive therapy (ECT—also known as electroshock therapy) involves giving electrical impulses to an anesthetized patient to intentionally induce seizures.   Treatments are typically administered by a psychiatrist and an anesthesiologist or anesthetist.

Electroconvulsive therapy is usually administered in an inpatient setting, but may be administered on an outpatient basis in a facility with treatment and recovery rooms.  It is usually administered 2 or 3 times a week, although ECT may be administered daily if tolerated.

The primary use of ECT is for major depressive disorder.  Electroconvulsive therapy is usually considered when medications fail, cannot be tolerated, or may be dangerous, but it is a first-line treatment for severely depressed patients who require a rapid response because of a high suicide or homicide risk, extreme agitation, life-threatening inanition, psychosis, or stupor.  The average course of treatment for depression is 6 to 12 treatments, but some patients may require as many as 20 treatments.

Electroconvulsive therapy has been found to be as or more effective than lithium in the treatment of manic episodes and is also a potential treatment for patients experiencing mixed episodes.  It is generally reserved for those patients with bipolar disorder who are unable to safely wait until a medication becomes effective, who are not responsive to or unable to safely tolerate one of the effective medications, is preferred by the patient in consultation with the psychiatrist, or who have had a good response to ECT in the past.  The number of ECT treatments reported to be effective for mania has ranged from 8 to 20.

Electroconvulsive therapy is not effective for chronic schizophrenia.  However, ECT may be effective for psychotic schizophrenic exacerbations when affective symptomatology is prominent, in catatonic schizophrenia, and when there is a history of a prior favorable response to ECT.  Schizophrenia may require 17 or more ECT treatments.

A small number of ECT treatments often reverse catatonia, a nonspecific symptom that can occur in mood disorders, schizophrenia, cognitive disorders, and medical and neurological illnesses.  Up to 12 treatments may be required in some patients.

Clinical experience suggests that ECT be continued until the patient has shown a maximal response; there is no evidence that administering 1 or 2 additional treatments results in a better outcome.  Indeed, increased confusion from additional treatments may produce clinical deterioration.  Electroconvulsive therapy is discontinued in patients who have had a partial but substantial improvement but show no change after 2 more treatments and in patients who have not responded at all after 6 to 10 treatments. Although ECT can be very effective for many individuals with serious mental illness, it is not a cure. To prevent a return of the illness, most people treated with ECT need to continue with some type of maintenance treatment. This typically means psychotherapy and/or medication or, in some circumstances, ongoing ECT treatments.

Relative contraindications to ECT include space-occupying lesions of the brain, high intracranial pressure, intracerebral bleeding, recent myocardial infarction, retinal detachment, pheochromocytoma, high anesthesia risk, adolescents and children, or a significant medical illness in which risk outweighs potential benefit.

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