Page 1 of 6 SECTION: Medical SUBJECT: Electroconvulsive Therapy (ECT) DATE OF ORIGIN: 10/1/96 REVIEW DATES: 7/1/98, 10/1/99, 7/1/02, 7/1/04, 10/1/05, 5/1/09, 1/3/13, 7/1/15, 8/1/16 EFFECTIVE DATE: 3/24/17 APPROVED BY: EXECUTIVE DIRECTOR MEDICAL DIRECTOR I. PURPOSE: To provide guidance for authorization of electroconvulsive therapy. II. DESCRIPTION/BACKGROUND: Electroconvulsive therapy (ECT) is a medical procedure in which a small electric current is passed through the brain for several seconds in order to cause seizure activity. Muscle relaxants are used to decrease the physical manifestations of the seizure upon the body. ECT is most often performed in a hospital s operating or recovery room and is always performed under general anesthesia. In acute services, ECT is typically given three times a week for a total of six to fifteen sessions. Additional sessions may be termed necessary depending on an individual s response to treatment. Maintenance, or continuation ECT, which may be required to help a remitted patient stay well, is administered once weekly to once every six weeks. III. COVERED SERVICES: A. Medical Necessity Criteria All of the following criteria are required to consider administration of ECT to patients 18 and older. 1. The patient must have been diagnosed with a psychiatric illness by a licensed psychiatrist, based on a face-to-face evaluation of the patient by that psychiatrist. 2. Symptoms of this illness must be in accord with those described in the current edition of the Diagnostic and Statistical Manual of Mental Disorders and must be amenable to ECT. 3. Two face-to-face psychiatric evaluations of the patient documenting the appropriateness of ECT are required unless the recommending psychiatrist is an ECT-credentialed psychiatrist, and the patient is at least 18 years of age and is his or her own legal guardian. At least one of the evaluating psychiatrists must be
Page 2 of 6 credentialed to perform ECT at a licensed treatment facility. 4. If the referring psychiatrist does not have ECT credentials at a licensed treatment facility, a second psychiatrist who does have ECT credentials will evaluate the patient and document the appropriateness of ECT. 5. In cases involving a guardian/durable Power of Attorney for healthcare (DPOA- HC), with specific authority to sign for ECT, two face-to-face psychiatric evaluations of the patient documenting the appropriateness of ECT are always required. At least one of the evaluating physicians must be credentialed to perform ECT at a licensed treatment facility. 6. In cases involving a patient with a court order for treatment, two face-to-face psychiatric evaluations of the patient documenting the appropriateness of ECT are always required. At least one of the evaluating psychiatrists must be credentialed to perform ECT at licensed treatment facility {refer to Section III: Consent [Michigan Mental Health Code (330.1717, Section 717 (1-6); 330.7017 (1-3)]}. 7. Within one month prior to beginning ECT, the patient must undergo a general medical history and examination in order to identify and stabilize medical conditions that could increase risks associated with ECT and anesthesia. 8. Within one month prior to beginning ECT, the patient must also receive an anesthetic evaluation addressing the anesthetic risk and advising of the need for modification in medications or anesthetic technique. 9. The type and severity of prominent target symptoms are described by the prescribing physician. 10. The individual has a treatment plan indicating target symptoms and specific criteria for remission. 11. The individual is evaluated by the prescribing physician or designee within 24 hours of every second treatment to evaluate and document improvement. The evaluator will use a standardized rating instrument. a) Treatment may be terminated if initial response is substantial but remains unchanged after two treatments. b) An individual showing slow or minimal improvement will be reevaluated by the prescribing physician after six treatments. This may result in termination or change in technique. 12. The prescribing physician for the ECT episode of care will support and facilitate appropriate coordination and transition to aftercare services and treatment. a) The prescribing physician will provide to the outpatient physician an ECT treatment summary, clinical documentation, and recommendations for ongoing treatment, including ECT and/or medication management. B. ECT Criteria Meeting one of the criteria below is sufficient for recommendation. The decision to use ECT depends on several factors, including the severity and chronicity of the condition, the likelihood that alternative treatments would be effective, the individual s preference and capacity to consent, and a weighing of the risks and benefits. 1. At least two courses of medication at maximum doses for an adequate length of time with good compliance have been ineffective or the symptoms of a psychiatric
Page 3 of 6 condition known to respond to ECT require a rapid response. Examples include: a) Severe depression with significant risk of suicide or failure to thrive in the elderly b) Severe mania c) Psychosis due to schizophrenia or schizoaffective disorder d) Catatonia e) Neuroleptic Malignant Syndrome 2. The patient has a history of positive response to ECT and a lack of response to medication in the past. 3. Use of psychotropic medication is compromised by the patient s medical condition. C. ECT Continuation Therapy and Maintenance Criteria 1. Continuation therapy is standard and its purpose is to prevent relapse. The risk of relapse is high in individuals resistant to psychotropic medication that display symptoms of a psychiatric condition known to respond to ECT. Continuation therapy is defined as treatment throughout the six-month period after remission of the index episode of mental illness. Continuation therapy is deemed medically necessary when a patient demonstrates a high risk for relapse. 2. Maintenance treatment is defined as treatment that extends and continues beyond six months. Maintenance treatment aims to protect against recurrence. Maintenance therapy is considered when: a) There is a strong history of recurrent illness. b) Past attempts to stop or taper symptoms have been inadequate or have prompted a return of symptoms. D. ECT is considered NOT medically necessary for the following conditions: 1. Substance Use Disorder is the primary diagnosis 2. Personality Disorders and Intellectual Disabilities 3. F34.1 (Persistent Depressive Disorder) unless this is a persisting condition when Major Depression with psychosis is absent 4. Management and control of acting-out behaviors 5. To aid in developing conditioned aversions to the taste, smell, and sight of alcoholic beverages 6. No evidence of ECT effectiveness in individuals who have been previously treated 7. Depression with ability to tolerate and respond to antidepressant medications 8. ECT should not be considered if previous treatment has been psychotherapy only 9. Network180 is not the responsible treating entity for primary medical conditions/ disorders or mental disorders due to medical conditions E. Special Considerations 1. Prior to an adolescent (over the age of 15) being referred for ECT treatment, two separate psychiatric evaluations by fellowship-trained child and adolescent psychiatrists (one of whom is not involved in the patient s treatment) should occur. 2. The elderly represent the largest age group of ECT patients. Age, unlike any other demographic indicator is a good predictor of positive response, though older
Page 4 of 6 individuals may require longer treatment episodes of two sessions per week instead of three. 3. The clinical effectiveness of multiple-seizure electroconvulsive therapy (MECT) has not been proven through scientifically controlled studies to be effective and thus will not be covered. F. Typical Service Utilization Pattern and Associated Outcomes 1. The determination of inpatient or outpatient settings as the appropriate level of care for administering ECT is determined by the ECT credentialed psychiatrist, based on the patient s clinical status with regard to both the presenting psychiatric illness and any other medical conditions. 2. Traditional sequence for ECT is every other day; under no circumstances is ECT to be performed more than once per day. 3. A course of ECT is generally six to fifteen sessions. If there is no discernible clinical improvement after six sessions, indications for continued ECT should be formally reassessed. Some patients may be referred for maintenance ECT, if clinically appropriate. 4. Only as many treatments as produce remission should be given. 5. Treatment may be stopped without tapering. However, if relapse occurs within two weeks, next course should be tapered to termination. G. Consent [Mental Health Code 330.1717, Section 717 (1-6); 330.7017 (1-3)] 1. A recipient shall not be the subject of electroconvulsive therapy or a procedure intended to provide convulsions or coma unless consent is obtained from the following: a) The recipient, if he or she is 18 years of age or older and does not have a guardian for medical purposes. b) The recipient s parent who has legal and physical custody of the recipient, if the recipient is less than 18 years of age. c) The recipient s guardian, if the guardian has power to execute consent to procedures described in this policy. d) The recipient s designated representative, if a durable power of attorney or other advance directive grants the representative authority to consent to procedures described in this policy. 2. If a guardian consents to procedures described in this policy, the procedures shall not be initiated until two psychiatrists have examined the recipient and documented in the recipient s record their concurrence with the decision to administer this procedure. 3. If a parent or guardian of a minor consents to a procedure described in the policy, the procedure shall not be initiated until two child and adolescent psychiatrists, neither of whom may be the treating psychiatrist, have examined the minor and documented in the minor s medical record their concurrence with the decision to administer the procedure. 4. A minor, or an advocate designated by the minor, may object to the administration of a procedure described in this policy. The objection shall be made either orally
Page 5 of 6 or in writing to the probate court. The procedure shall not be initiated before a court hearing on the minor s or advocate s objection. 5. At least 72 hours, excluding Sundays or holidays, before the initiation of the procedure described in this policy, a minor shall be informed that he or she has a right to object to the procedure. 6. If a procedure described in this policy is considered advisable for a recipient and an individual eligible to give consent for the procedure is not located after diligent effort, a probate court may, upon petition and after a hearing, consent to administration of the procedure in lieu of the individual eligible to give consent. 7. A provider shall comply with the following provisions when administering ECT: a) A provider shall enter written documentation and signed consent in the clinical record. b) A provider shall consent for a stated number of electroconvulsive treatments within a series during a stated time period. c) A provider shall inform a recipient or other legally empowered representative that he or she may withdraw his or her consent at any time during the stated time period. 8. The responsible mental health agency shall notify a minor or an advocate designated by the minor of the right to object to a procedure as specified above. A provider shall place documentation of the notification, including the date and time notified in the record. 9. The responsible mental health agency shall assist a minor or an advocate designated by the minor who objects to electroconvulsive procedure in properly submitting the objection to a court of competent jurisdiction. IV. MEDICAL NECESSITY REVIEW: Required Not Required Not Applicable V. CODING INFORMATION: A. ICD-10 Diagnosis Codes These diagnoses may support medical necessity: 1. G21.0 Neuroleptic Malignant Syndrome 2. F20.0 F20.9, F25.0 F25.1, F25.8 F25.9 Schizophrenic Disorders 3. F30.10 30.13, 30.2 30.4, 30.8, 31 31.9, 32.0 32.9, 33.0 33.9, 34.8, 39 Episodic Mood Disorders B. Revenue Codes 1. 0901 Electroshock Treatment (ECT) VI. REFERENCES Michigan Department of Health and Human Services (MDHHS); Medicaid Provider Manual
Page 6 of 6 Centers for Medicare and Medicaid Services (CMS); Standards and Criteria for Utilization Management Michigan Mental Health Code; [330.1717, Section 717 (1-6); 330.7017 (1-3)] Tess, A.V., Smetana, G.W. Medical Evaluation of Patients Undergoing Electroconvulsive Therapy. N Engl J Med 2009; 360: 1437-44 The Practice of Electroconvulsive Therapy, A Task Force Report of the American Psychiatric Association, Second Edition, 2001 VII. ATTACHMENTS A. Initial Request for Outpatient ECT Authorization B. Outpatient ECT Reauthorization Request Form