Medical Policy

Effective Date:01/01/2021 Title:Electroconvulsive Therapy (ECT)
Revision Date: Document:BI672:00
CPT Code(s):00104, 90870
Public Statement

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 Statement

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)

Limits

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)

Reference

1.    Abdulwadud O. Electro convulsive therapy (ECT) in the management of bipolar mood disorder during pregnancy. Evidence Centre Critical Appraisal. Clayton, VIC: Centre for Clinical Effectiveness (CCE); 2001.

2.    Amanullah S, Delva N, McRae H, et al. Electroconvulsive therapy in patients with skull defects or metallic implants: A review of the literature and case report. Prim Care Companion CNS Disord. 2012;14(2).

3.    American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 1998;37(10 Suppl):63S-83S.

4.    American Psychiatric Association. Practice guideline for major depressive disorder in adults. Am J Psychiatry. 1993;150(4 Suppl):1-26.

5.    American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder. Am J Psychiatry. 1994;151(12 Suppl):1-36.

6.    American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry. 1997;154(4 Suppl):1-63.

7.    American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156(5 Suppl):1-20.

8.    American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder. Am J Psychiatry. 2002;159(4 Suppl):1-50.

9.    American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. Am J Psychiatry. 2000;157(4 Suppl):1-45.

10. American Psychiatric Association. The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging: A task force report of the American Psychiatric Association, 2nd ed. Washington, DC: American Psychiatric Association Press; 2001.

11. Asadi-Pooya AA, Razavizadegan MA, Sahraian A, Sahmeddini MA. Adjunctive use of electroconvulsive therapy in patients with Lennox-Gastaut syndrome and drug-resistant epilepsy: A pilot study. Med J Islam Repub Iran. 2016;30:413.

12. Bahji A, Hawken ER, Sepehry AA, et al. ECT beyond unipolar major depression: Systematic review and meta-analysis of electroconvulsive therapy in bipolar depression. Acta Psychiatr Scand. 2019;139(3):214-226.

13. Banken R. The use of electroconvulsive therapy in Quebec. AETMIS 02-05 RE. Montreal, QC: Agence d`Evaluation des Technologies et des Modes d`Intervention en Sante (AETMIS); 2002.

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21. Coffey MJ, Cooper JJ. Electroconvulsive therapy in anti-N-Methyl-D-aspartate receptor encephalitis: A case report and review of the literature. J ECT. 2016;32(4):225-229.

22. Consoli A, Benmiloud M, Wachtel L, et al. Electroconvulsive therapy in adolescents with the catatonia syndrome: Efficacy and ethics. J ECT. 2010;26(4):259-265.

23. Cybulska EM. Obsessive-compulsive disorder, the brain and electroconvulsive therapy. Br J Hosp Med (Lond). 2006;67(2):77-81.

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30. Geddes J, Carney S, Cowen P, et al. Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. Lancet. 2003;361(9360):799-808.

31. Ghaziuddin N, Kutcher SP, Knapp P, et al. Practice parameter for use of electroconvulsive therapy with adolescents. J Am Acad Child Adolesc Psychiatry. 2004;43(12):1521-1539.

32. Glass OM, Forester BP, Hermida AP. Electroconvulsive therapy (ECT) for treating agitation in dementia (major neurocognitive disorder) - a promising option. Int Psychogeriatr. 2017;29(5):717-726.

33. Gough JL, Coebergh J, Chandra B, Nilforooshan R. Electroconvulsive therapy and/or plasmapheresis in autoimmune encephalitis? World J Clin Cases. 2016;4(8):223-228.

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38. Gu X, Zheng W, Guo T, et al. Electroconvulsive therapy for agitation in schizophrenia: Metaanalysis of randomized controlled trials. Shanghai Arch Psychiatry. 2017;29(1):1-14.

39. Hackett ML, Anderson CS, House A, Xia J. Interventions for treating depression after stroke. Cochrane Database Syst Rev. 2008;(4):CD003437.

40. Hazell P. Depression in children and adolescents (updated). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; April 2008.

41. Jankovic J. Tourette syndrome. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2015.

42. Jimenez-Cornejo M, Zamorano-Levi N, Jeria A. Is electroconvulsive therapy during pregnancy safe? Medwave. 2016;16(Suppl5):e6790.

43. Kennedy SH, Milev R, Giacobbe P, et al; Canadian Network for Mood and Anxiety Treatments (CANMAT). Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies. J Affect Disord. 2009;117 Suppl 1:S44-S53.

44. Kho KH, van Vreeswijk MF, Simpson S, Zwinderman AH. A meta-analysis of electroconvulsive therapy efficacy in depression. J ECT. 2003;19(3):139-147.

45. Lally J, Tully J, Robertson D, et al. Augmentation of clozapine with electroconvulsive therapy in treatment resistant schizophrenia: A systematic review and meta-analysis. Schizophr Res. 2016;171(1-3):215-224.

46. Leaver AM, Wade B, Vasavada M, et al. Fronto-temporal connectivity predicts ECT outcome in major depression. Front Psychiatry. 2018;9:92.

47. Lehman AF, Lieberman JA, Dixon LB, et al. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 2004;161(2 Suppl):1-56.

48. Leiknes KA, Cooke MJ, Jarosch-von Schweder L, et al.  Electroconvulsive therapy during pregnancy: A systematic review of case studies. Arch Womens Ment Health. 2015;18(1):1-39.

49. Levy-Rueff M, Gourevitch R, Lôo H, et al. Maintenance electroconvulsive therapy: An alternative treatment for refractory schizophrenia and schizoaffective disorders. Psychiatry Res. 2010;175(3):280-283.

50. Lima NN, Nascimento VB, Peixoto JA, et al. Electroconvulsive therapy use in adolescents: A systematic review. Ann Gen Psychiatry. 2013;12(1):17.

51. Loo CK, Katalinic N, Martin D, Schweitzer I. A review of ultrabrief pulse width electroconvulsive therapy. Ther Adv Chronic Dis. 2012;3(2):69-85.

52. Luan S, Zhou B, Wu Q, et al. Brain-derived neurotrophic factor blood levels after electroconvulsive therapy in patients with major depressive disorder: A systematic review and meta-analysis. Asian J Psychiatr. 2020 Feb 26;51:101983 [Epub ahead of print].

53. Margoob MA, Ali Z, Andrade C. Efficacy of ECT in chronic, severe, antidepressant- and CBT-refractory PTSD: An open, prospective study. Brain Stimul. 2010;3(1):28-35.

54. McClellan J, Werry J; American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 1997;36 (10 Suppl):157S-176S.

55. McLoughlin DM, Mogg A, Eranti S, et al. The clinical effectiveness and cost of repetitive transcranial magnetic stimulation versus electroconvulsive therapy in severe depression: A multicentre pragmatic randomised controlled trial and economic analysis. Health Technol Assess. 2007;11(24):1-54.

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58. National Institute for Health and Clinical Excellence (NICE). Obsessive compulsive disorder: Core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder. Clinical Practice Guideline No. 31. London, UK; NICE; January 25, 2006. Available at: http://www.nice.org.uk/page.aspx?o=289817. Accessed May 23, 2007.

59. Niu Y, Ye D, You Y, Wu J. Prophylactic cognitive enhancers for improvement of cognitive function in patients undergoing electroconvulsive therapy: A systematic review and meta-analysis. Medicine (Baltimore). 2020;99(11):e19527.

60. Okazaki R, Takahashi T, Ueno K, et al. Changes in EEG complexity with electroconvulsive therapy in a patient with autism spectrum disorders: A multiscale entropy approach. Front Hum Neurosci. 2015;9:106.

61. Oudman E. Is electroconvulsive therapy (ECT) effective and safe for treatment of depression in dementia? A short review. J ECT. 2012;28(1):34-38.

62. Pacilio RM, Livingston RK, Gordon MR. The use of electroconvulsive therapy in eating disorders: A systematic literature review and case report. J ECT. 2019;35(4):272-278.

63. Pompili M, Lester D, Dominici G, et al. Indications for electroconvulsive treatment in schizophrenia: A systematic review. Schizophr Res. 2013;146(1-3):1-9.

64. Rasmussen KG, Mueller M, Rummans TA, et al. Is baseline medication resistance associated with potential for relapse after successful remission of a depressive episode with ECT? Data from the Consortium for Research on Electroconvulsive Therapy (CORE). J Clin Psychiatry. 2009;70(2):232-237.

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78. van den Berg JF, Kruithof HC, Kok RM, et al. Electroconvulsive therapy for agitation and aggression in dementia: A systematic review. Am J Geriatr Psychiatry. 2018;26(4):419-434.

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80. van Herck E, Sienaert P, Hagon A. Electroconvulsive therapy for patients with intracranial aneurysms: A case study and literature review. Tijdschr Psychiatr. 2009;51(1):43-51.

81. Vann Jones S, McCollum R. Subjective memory complaints after electroconvulsive therapy: Systematic review. BJPsych Bull. 2019;43(2):73-80.

82. Wang W, Pu C, Jiang J, et al. Efficacy and safety of treating patients with refractory schizophrenia with antipsychotic medication and adjunctive electroconvulsive therapy: A systematic review and meta-analysis. Shanghai Arch Psychiatry. 2015;27(4):206-219.

83. Wilkins KM, Ostroff R, Tampi RR. Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: A review of the literature. J Geriatr Psychiatry Neurol. 2008;21(1):3-11.

84. Youssef NA, McCall WV, Andrade C. The role of ECT in posttraumatic stress disorder: A systematic review. Ann Clin Psychiatry. 2017;29(1):62-70.

85. Zeiler FA, Matuszczak M, Teitelbaum J, et al. Electroconvulsive therapy for refractory status epilepticus: A systematic review. Seizure. 2016;35:23-32.

86. Erdil F, Ozgul U, Çolak C, et al. Effect of the addition of ketamine to sevoflurane anesthesia on seizure duration in electroconvulsive therapy. J ECT. 2015;31(3):182-185.

87. Fernie G, Currie J, Perrin JS, et al. Ketamine as the anaesthetic for electroconvulsive therapy: The KANECT randomised controlled trial. Br J Psychiatry. 2017;210(6):422-428.

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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.