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)

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