BlueCross and BlueShield of Montana Medical Policy/Codes
Electroconvulsive Therapy
Chapter: Mental Health
Current Effective Date: October 25, 2013
Original Effective Date: October 25, 2013
Publish Date: July 25, 2013
Description

ECT involves the intentional induction of generalized seizures to the anesthetized patient by administering electrical impulses to the brain for up to several seconds through scalp electrodes to produce a therapeutic effect. Treatments are typically administered by a psychiatrist and an anesthesiologist or anesthetist. Patients are monitored throughout the procedure, which takes about 10 to 15 minutes. ECT is usually administered in an inpatient setting, but can be administered in an outpatient facility with treatment and recovery rooms. ECT is usually administered two or three times a week, although ECT may be administered daily if tolerated.

In MMECT, a patient undergoes ECT in the usual manner, but before regaining consciousness, undergoes another session of ECT designed to elicit a second (or additional) seizure. The effectiveness of MMECT has not been established.

Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.   Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.   If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Electroconvulsive therapy (ECT) may be considered medically necessary for patients who meet all the following criteria:

  • Patient is diagnosed with one of the following conditions:
    • Major depression,
    • Mania,
    • Catatonia (a non-specific symptom that can occur in mood disorders, schizophrenia, cognitive disorders, and medical and neurological illnesses),
    • Certain acute schizophrenic exacerbations (i.e., psychotic schizophrenia when affective symptomatology is present), AND
  • Patient is at least 12 years of age; AND
  • One or more of the following criteria is met:
    • Patient is unresponsive to effective medications (adequate dose and duration) that are indicated for the patient’s condition (e.g., antidepressants, antipsychotics, etc., as appropriate), or
    • Patient is unable to tolerate effective medications or has a medical condition for which medication is contraindicated, or
    • Patient has had favorable response to ECT in the past, or
    • Patient is unable to safely wait until medication is effective, due to inanition (a condition characterized by marked weakness, extreme weight loss, and a decrease in metabolism resulting from prolonged and severe insufficiency of food), stupor, extreme agitation, high suicide or homicide risk, etc.

NOTE: It is rare that a patient will receive more than 20 treatments in a treatment series.

Electroconvulsive therapy (ECT) is considered experimental, investigational, and/or unproven for all other indications. 

Multiple monitored electroconvulsive therapy (MMECT) is considered experimental, investigational and/or unproven as its effectiveness has not been established.

Policy Guidelines

CPT code 90870 includes the following monitoring procedures which cannot be billed separately by either a psychiatrist or by an anesthesiologist administering the anesthetic:

  • Electroencephalogram (EEG) monitoring;
  • Cardiac monitoring;
  • Pulse oximetry.

Anesthesia is payable separately when billed by a different provider other than the physician administering the ECT. 

Rationale

The primary indication for ECT is major depressive disorder. ECT 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, inanition, or stupor. The average course of treatment for depression is 6 to 12 treatments, but some patients may require as many as 20.

ECT has been found to be more effective than Lithium in the treatment of manic episodes. ECT 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, 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.

ECT 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.

There is very limited evidence that ECT is effective for delirium. In addition, there may be considerable risks with ECT in medically unstable patients. For these reasons, in 1999, the American Psychiatric Association (APA) concluded that ECT "has not been shown to be an effective treatment for general cases of delirium." The APA recommends that ECT be "considered only rarely for patients with delirium due to specific etiologies such as neuroleptic malignant syndrome and should not be considered initially as a substitute for more conservative and conventional treatments." ECT requests for delirium should be forwarded to the behavioral health medical director for review.

A few clinicians have reported the successful use of ECT in severe obsessive-compulsive disorder, anorexia nervosa, atypical psychosis, cycloid psychosis, epilepsy with alternating psychosis, and chronic pain disorder. Those disorders are not usually considered indications for ECT. Requests for ECT for these indications should be forwarded to the behavioral health medical director for review. 

ECT is not an effective treatment for dysthymic disorder, neuroses, dissociative disorders, hypochondriasis, conversion disorder, substance-related disorders, and personality disorders.

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 when a significant medical illness is present in which the risk outweighs the potential benefit.

The effectiveness of MMECT has not been established. The National Institutes of Health 1985 Consensus Development Conference Statement on ECT states that "Multiple monitored ECT (several seizures during a single treatment session) has not been demonstrated to be sufficiently effective to be recommended."

2013 Update

The National Institute for Health and Care Excellence (NICE) recommends that ECT is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and when the condition is considered to be potentially life-threatening in individuals with catatonia and when prolonged or severe manic episodes are identified. (10)  They also support the use of ECT with severe depression and complex depression where there is risk to life or severe self-neglect. Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorbidity or psychosocial factors. Treatment options include medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care. (11)

A study completed in March 2012 by E. Oudman indicated that depression is one of the most frequently diagnosed psychiatric disorders in patients with dementia with a prevalence of up to 50%. The detrimental effects of depression in dementia include disability in daily living, worse quality of life, and faster cognitive decline. Although ECT is a well-established and effective treatment for depression in the elderly, it is currently an overlooked treatment option in the elderly with dementia and depression. The aim of this review was to provide a critical analysis of the efficacy and safety of ECT in depression superimposed on dementia by reviewing the current literature on this topic. Current evidence suggests that ECT is an effective treatment for depression in dementia, although the relatively small number of controlled studies hampers the comparison of effectiveness between healthy non geriatric patients and those with dementia. Moreover, the systematic reports on cognitive side effects are very limited in number and currently only apply to moderately mild or mild dementia of nonvascular origin. Some studies do suggest that cognitive side effects are likely in later stages of dementia and in patients with vascular dementia. It is therefore of crucial relevance to prospectively study effects of ECT in different types and phases of dementia in controlled trials. From a clinical perspective, it is essential to inform and educate patients and family about the possible risks and benefits of ECT treatment for depression in dementia. (12)

In 2012, Ujkaj, et al. examined the safety and effectiveness of ECT for agitation and aggression in dementia patients. The retrospective review included sixteen patients with a diagnosis of dementia treated with ECT for agitation/aggression during 2004-2007. There were 16 patients of mean age 66.6 ± 8.3 years were studied. Their average overall and pre-ECT lengths of stay were 59.7 ± 39.7 days and 23 ± 15.7 days, respectively. Patients received a mean of 9 ECT treatments, mostly bilateral. Patients showed significant reductions in their total Pittsburgh Agitation Scale scores from baseline after ECT (from 11.0 ± 5.0 to 3.9 ± 4.3 [F = 30.33, df = 1, 15, p < 0.001]). Clinical Global Impression scale decreased significantly (from 6.0 ± 0.6 pre-ECT to 2.1 ± 1.6 post-ECT [F = 112.97, df = 1, 15, p < 0.001]). Global Assessment of Functioning change was not significant (from 23.0 ± 4.9 to 26.9 ± 6.9 [F = 5.73, df = 1, 13, p = 0.32]). Only one patient, in whom ECT was discontinued following 11 bilateral treatments, showed no improvement. Eight patients showed transient postictal confusion, which typically resolved within 48 hours. Two patients showed more severe postictal confusion that required modification of treatment. In conclusion, the results suggest that ECT is an effective and safe treatment for agitation and aggression in dementia. Further prospective studies are warranted. (13)

A 2005 study by Dr. Bernando Dell’Osso, et al. evaluated brain stimulation techniques in the treatment of Obsessive-Compulsive Disorders (OCD). Studies on the epidemiology of OCD estimate 50 million patients suffer from OCD worldwide, thus making it a global problem. The treatment of OCD has changed substantially over the last 2 decades following the introduction of selective serotonin reuptake inhibitors, which provide symptom improvement in approximately 60% of patients. However, some patients remain resistant to the standard pharmacologic and behavioral treatments. Although some treatment-resistant patients respond to pharmacologic augmentations, others do not, and there is evidence that some of the most severe cases benefit from treatment with neurosurgical interventions. Besides pharmacologic, behavioral, and neurosurgical approaches, different brain stimulation methods-transcranial magnetic stimulation, deep brain stimulation, and electroconvulsive therapy-have been investigated in treatment-resistant patients with OCD. However, available data about the use of these techniques in OCD treatment are quite limited in terms of sample size and study design, given the difficulty in conducting standard blinded trials for these procedures. In addition, none of the mentioned treatments have received Food and Drug Administration (FDA) approval for the treatment of OCD. Nevertheless, promising findings regarding efficacy, tolerability, and non-invasiveness and/or reversibility of these techniques have increased interest in investigating their use in treatment-resistant OCD. (14)

A search of peer reviewed literature through August 2013 identified new clinical trial publications that do not change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

94.27, 290.12, 290.13, 290.20, 290.21, 290.42, 290.43, 293.83, 294.10, 294.10, 294.11, 295.20 to 295.24, 295.20 to 295.94, 296.00 to 296.99, 298.0 to 298.9, 300.4, 311, 331.0, 331.1, 331.2, 333.4, 995.2

Procedural Codes: 00104, 90870
References
  1. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. Electroconvulsive Therapy. National Institutes of Health Consensus Development Conference Statement. Bethesda, MD: NIH (1985 June 10-12).
  2. McClellan, J., Werry, J., et al. Practice Parameters for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry (1997 Oct) 36 (10 Supplement):157S-76S.
  3. AACAP official action. Practice Parameters for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry (1997 Jan) 36(1):138-57.
  4. Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. Second Edition. American Psychiatric Association, (2000 April):61-78.
  5. Ciapparelli, A., Dell'Osso, L., et al. Electroconvulsive therapy in medication-nonresponsive patients with mixed mania and bipolar depression. Journal of Clinical Psychiatry (2001 July 7)62(7); 552-5.
  6. Noncoverage of Multiple Electroconvulsive Therapy (MECT). Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS) (2003 January 10).
  7. Centers for Medicare and Medicaid, NCD for Multiple Electroconvulsive Therapy (MECT) (160.25) Publication Number 100-3, Manual Section Number 160.25, Version 1 (2003 April 1).
  8. UK EVCT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders; a systematic review and meta-analysis. Lancet (2003 March 8) 361(9360):799-808.
  9. McLoughlin, D.M., Mogg, A., et al. The clinical effectiveness and cost of repetitive transcranial magnetic stimulation versus electroconvulsive therapy in severe depression: a multicenter pragmatic randomized controlled trial and economic analysis. Health Technology Assessments (2007 July) 11(24):1-54.
  10. National Institute for Health and Care Excellence, Guidance on the use of Electroconvulsive Therapy, April 2003 (modified October 2009). www.nice.org .
  11. National Institute for Health and Care Excellence, Depression in adults: The treatment and management of depression in adults, October 2009. www.nice.org .
  12. 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.
  13. Ujkaj M, Davidoff DA, Seiner SJ, et al. Safety and efficacy of electroconvulsive therapy for the treatment of agitation and aggression in patients with dementia. Am J Geriatr Psychiatry 2012 Jan; 20(1):61-72.
  14. Dell’Osso B, et al. Brain stimulation techniques in the treatment of Obsessive-compulsive disorder: current and future directions. December 2005:10(12):966-79, 983.
History
July 2013  New 2013 BCBSMT medical policy.
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Electroconvulsive Therapy