Pending Policies - Mental Health


Electroconvulsive Therapy

Number:PSY301.013

Effective Date:11-15-2017

Coverage:

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

1. Patient is diagnosed with one of the following conditions:

a. Major depression,

b. Mania,

c. Catatonia (a non-specific symptom that can occur in mood disorders, schizophrenia, cognitive disorders, and medical and neurological illnesses),

d. Certain acute schizophrenic exacerbations (i.e., psychotic schizophrenia when affective symptomatology is present), AND

2. Patient is at least 12 years of age; AND

3. One or more of the following criteria is met:

a. 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

b. Patient is unable to tolerate effective medications or has a medical condition for which medication is contraindicated, or

c. Patient has had favorable response to ECT in the past, or

d. 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.

Description:

Electroconvulsive Therapy (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 multiple monitored electroconvulsive therapy (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.

Rationale:

The primary indication for electroconvulsive therapy (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. (1-3)

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. (4-5)

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.

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. In addition, studies have demonstrated an increased risk of adverse effects with multiple seizures. (8,9)

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. (11)

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. (12)

A 2005 study by 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 U. S. 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. (13)

Practice Guidelines and Position Statements

National Institute of Health (NIH)

The NIH 1985 Consensus Development Conference Statement on electroconvulsive therapy (ECT) states that "Multiple monitored ECT (MMECT) (several seizures during a single treatment session) has not been demonstrated to be sufficiently effective to be recommended." (14)

American Psychiatric Association (APA)

In 1999, the 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. This is due to the limited evidence that ECT is effective for delirium and that there may be considerable risks with ECT in medically unstable patients. (15) Since the APA’s Practice Guidelines for the Treatment of Patients with Delirium was published in 1999, advances in different areas including the clinical neurosciences have contributed to the understanding of delirium. (16) Although there has been no formal update to the guidelines, in 2004, a “Guideline Watch” was released which summarized the progress in this area. There was no mention of ECT for the management of delirium.

In 2015, the APA reaffirmed the currency of the practice guideline for the treatment of patients with major depressive disorder and inclusive in the recommendations for ECT are the following (3):

Acute Phase - “ECT is recommended as a treatment of choice for patients with severe major depressive disorder (MDD) that is not responsive to psychotherapeutic and/or pharmacological interventions, particularly in those who have significant functional impairment or have not response do numerous medication trials [I], for individuals with MDD who have associated psychotic or catatonic features [I], for those with an urgent need for response (e.g., patients who are suicidal or nutritionally compromised due to refusal of food or fluids [I], and for those who prefer ECT or have had a previous positive response to ECT [II].”

Continuation Phase - “patients who have responded to an acute course of ECT may be given continuation ECT, particularly if medication or psychotherapy has been ineffective in maintaining remission [II].”

Maintenance Phase - “For patients whose depressive episodes have not previously responded to acute or continuation treatment with medications or a depression-focused psychotherapy but who have shown a response to ECT, maintenance ECT may be considered [III].”

Categories of Endorsement used above include: [I]Recommended with substantial clinical confidence; [II]Recommended with moderate clinical confidence and [III]May be recommended on the basis of individual circumstances.

National Institute for Health and Care Excellence (NICE)

The 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. (17) 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. (18)

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description 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, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

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.

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.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

00104, 90870

HCPCS Codes

N/A

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Kellner, Charles. Overview of electroconvulsive therapy (ECT) for adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Available at <https://www.uptodate.com> (accessed - 2016 October 17).

2. Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. Second Edition. American Psychiatric Association, (2000 April):61-78. PMID 10767867

3. Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. Third Edition. American Psychiatric Association, (Revised 2010; Reaffirmed 2015). Available at <https://www.guideline.gov> (accessed - 2016 October 10).

4. McClellan, J., Werry, J., et al. Practice Parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child and Adolesc Psychiatry (1997 Oct) 36 (10 Supplement):157S-76S. PMID 9432516

5. McClellan, J., Kowatch, R., et al. Practice Parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child and Adolesc Psychiatry (2007 Jun) 46 (6):786. PMID 17195735

6. 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. PMID 9000791

7. 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. PMID 11488367

8. Noncoverage of Multiple Electroconvulsive Therapy (MECT). Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS) (2003 January 10). Available at <https://www.cms.gov> (accessed - 2016 October 10).

9. 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). Available at <https://www.cms.gov> (accessed - 2016 October 10)

10. 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. PMID 12642045

11. 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.

12. 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.

13. Dell’Osso B, Altamura A.C., et al. Brain stimulation techniques in the treatment of Obsessive-compulsive disorder: current and future directions. December 2005:10(12):966-79, 983. PMID 16344833

14. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. Electroconvulsive Therapy (Archived). National Institutes of Health Consensus Development Conference Statement. Bethesda, MD: NIH (1985 June 10-12). PMID 3908919

15. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999; 156(5 Suppl):1-20. PMID 10327941

16. American Psychiatric Association. Guideline Watch: Practice Guideline for the treatment of patients with delirium (2004). Available at <http://psychiatryonline.org> (accessed - 2016 October 12).

17. National Institute for Health and Care Excellence, Guidance on the use of Electroconvulsive Therapy, April 2003 (modified October 2009). Available at <https://www.nice.org> (accessed - 2016 October 10).

18. National Institute for Health and Care Excellence, Depression in adults: The treatment and management of depression in adults, October 2009. Available at <https://www.nice.org> (accessed - 2016 October 10).

Policy History:

Date Reason
11/15/2017 Reviewed. No changes.
12/1/2016 Document updated with literature review. Coverage unchanged.
1/15/2015 Reviewed. No changes.
11/1/2013 Document updated with literature review. Coverage unchanged.
9/1/2007 Document updated with literature review. Coverage revised. CPT/HCPCS code(s) updated.
3/15/2005 Document updated with literature review. Coverage unchanged. The following change(s) were made: Rationale, Description, References, and Title Revised. CPT/HCPCS code(s) updated with bit changes.
2/27/2004 New Medical Document

Archived Document(s):

Title:Effective Date:End Date:
Electroconvulsive Therapy11-01-202110-14-2022
Electroconvulsive Therapy12-15-202010-31-2021
Electroconvulsive Therapy06-15-201912-14-2020
Electroconvulsive Therapy11-15-201706-14-2019
Electroconvulsive Therapy12-01-201611-14-2017
Electroconvulsive Therapy01-15-201511-30-2016
Electroconvulsive Therapy11-01-201301-14-2015
Electroconvulsive Therapy09-01-200710-31-2013
Electroconvulsive Therapy02-27-200408-31-2007
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