Medicare Advantage

Medical Policy

Notification

Electroconvulsive Therapy (ECT)

Notification Issue Date:

This version of the policy will become effective 01/01/2023. The following new policy has been developed to address coverage criteria for Electroconvulsive Therapy (ECT).

Title:

Electroconvulsive Therapy (ECT)

Policy #:

MA14.001a

Policy

MEDICALLY NECESSARY

Electroconvulsive therapy (ECT) is considered medically necessary and, therefore, covered for one or more of the following:

Acute treatment (generally administered 2–3 times per week with a total treatment course ranging from 6–12 treatments) of a psychiatric condition amenable to ECT, as indicated by ALL of the following:

Diagnosis of one or more of the following:

Major depressive disorder (unipolar disorder)
Bipolar disorder
Schizophrenia and schizoaffective disorders

Need for ECT, as indicated by one or more of the following:

Catatonia
High risk for suicide attempt
Inadequate response to pharmacotherapy despite ALL of the following:

Adequate duration and dosage
Documented adherence
Trials from two or more classes of medications

Intractable manic excitement
Neuroleptic malignant syndrome
Nutritional compromise
Pharmacotherapy not preferred due to risk of adverse effects (e.g., pregnant or elderly individuals) or documented intolerance
Unremitting self-injury

Pretreatment symptoms rated as severe
Individual has undergone medical review and clearance

Extension of acute treatment of a psychiatric condition amenable to ECT, as indicated by ALL of the following:

Partial positive response to acute treatment
Treatment is being re-evaluated and modified (e.g., modification of stimulus parameters)

Continued treatment of a psychiatric condition amenable to ECT, as indicated by ALL of the following:

Clinical determination that continued treatment is needed to reduce risk of relapse (e.g., previous relapse without ECT)
Adjunctive pharmacotherapy optimized as indicated, or documented intolerance or inadequate response to pharmacotherapy
Sessions tapered to lowest frequency that maintains response (e.g., weekly, biweekly, monthly)

EXPERIMENTAL/INVESTIGATIONAL

ECT is considered experimental/investigational and, therefore, not covered for all other conditions, including but not limited to the following, because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature:

Autism spectrum disorder
Dementia-associated agitation and aggression
Parkinson's disease

Guidelines

This policy is consistent with Medicare’s coverage determination for electroconvulsive therapy (ECT). The Company’s payment methodology may differ from Medicare.

The diagnosis and severity of depressive disorders may be confirmed and documented by the use of standardized rating scales that reliably measure depressive symptoms. For adults, these scales include the following:

Beck Depression Inventory (BDI)
Hamilton Depression Rating Scale (HDRS)
Patient Health Questionnaire-9 (PHQ-9) in the primary care setting
Montgomery-Asberg Depression Rating Scale (MADRAS)
Geriatric Depression Scale (GDS) for older adults

For children and adolescents, these scales include the following:

Beck Depression Inventory (BDI)
Children's Depression Inventory (CDI)
Patient Health Questionnaire-9 (PHQ-9) modified for adolescents (PHQ-A)

The PHQ-9 and PHQ-A ask the individual to describe the frequency of nine symptoms during the past 2 weeks on a scale of 0 to 3 (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day). Depression severity is scored as follows: 0 to 4 (none), 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe). In addition to screening, rating scales are often administered throughout treatment to measure changes in symptoms. An approximate 50% decrease in scores on the BDI, HDRS, PHQ-9/PHQ-A, or the MADRAS has been found to be clinically significant.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, ECT is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

Electroconvulsive Therapy (ECT) applies electrical stimuli to the brain via scalp electrodes to induce seizures. It is administered under general anesthesia and may be performed in either inpatient or outpatient settings. Risks of ECT are primarily those associated with anesthesia, so pretreatment medical review is required. Cognitive dysfunction, including disorientation and anterograde and retrograde amnesia, is the most significant side effect (Allan and Ebmeier, 2011; McClintock et al., 2014). ECT is not recommended for individuals with active cardiac disease (e.g., myocardial ischemia, arrhythmia), cerebrovascular disease (e.g., cerebral hemorrhage, stroke), or increased intracranial pressure (e.g., due to space-occupying lesion) due to an increased risk of periprocedural complications (Lisanby, 2007).

ACUTE TREATMENT

Acute ECT is generally administered two to three times per week with a total treatment course ranging from six to 12 treatments (Allan and Ebmeier, 2011; Lisanby, 2007). Early symptom improvement has been found to be associated with an increased likelihood of attaining response and remission (Lin et al., 2016).

CONTINUATION OR MAINTENANCE TREATMENT

Continuation of ECT treatment beyond 12 sessions is generally reserved for individuals who have achieved partial response, and may be initiated after assessment for diagnostic and treatment characteristics that may predispose the individual to a less favorable outcome (e.g., medical and psychiatric comorbidities, electrode placement, stimulus and seizure characteristics, medication interaction, adverse effects) (Lisanby, 2007; Kellner et al., 2017; Kumar et al., 2016).

Systematic reviews have found that maintenance ECT prevents relapse and recurrence of major depression and treatment-resistant depression, particularly when provided in combination with antidepressant medication (Brown et al., 2014; Youssef and McCall, 2014; Van Schaik et al., 2012; Petrides et al., 2011).

ECT DURING PREGNANCY

Although data are limited, ECT is relatively safe when administered during the first trimester of pregnancy. The risk of administration of ECT in the first trimester of pregnancy must be weighed against the risk of untreated mental illness in the same individual (Calaway et al., 2016; Ray-Griffith et al., 2016; Coshal et al., 2019).

ECT IN CHILDREN AND ADOLESCENTS

A professional society guideline supports the use of ECT in children and adolescents provided the individual has been diagnosed with severe major depressive disorder (unipolar disorder), mania, schizoaffective disorder, schizophrenia, catatonia, or neuroleptic malignant syndrome with life-threatening or persistently disabling symptoms and failure of at least two adequate prior treatments when feasible. Evaluation by a second provider not directly involved in the individual's care and with specific knowledge of ECT is advised (Ghaziuddin et al., 2004; Benson and Seiner, 2019; Dhossche and Withane, 2019).

ALTERNATIVE TREATMENTS TO ECT

Alternative treatments to ECT include:

For major depressive disorder:

Antidepressant medication
Psychotherapy
Antidepressant/psychotherapy combination treatment
Transcranial magnetic stimulation
Bright light therapy, for individuals with depression and seasonal component

For other conditions, conventional management of condition (e.g., pharmacotherapy)

Systematic reviews and meta-analyses of randomized trials comparing repetitive transcranial magnetic stimulation (rTMS) and ECT have found both to be effective in treating depression, but ECT appears to be superior in individuals with more severe symptoms as well as in individuals with psychotic depression (Micallef-Trigona, 2014; Berlim et al., 2013; Ren et al., 2014).

AUTISM SPECTRUM DISORDER (ASD)

For autism spectrum disorder (ASD), evidence is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit versus harm; additional research is recommended. A review article states that case reports and series have documented the safe and effective use of ECT in children, adolescents, and young adults with ASD who present with severe, intractable, repetitive self-injurious behavior, although frequent maintenance therapy is usually needed to sustain the benefit (D'Agati et al., 2017).

Although some studies suggest the use of ECT for self-injurious behavior in pediatric and adolescent individuals diagnosed with ASD and catatonia, most studies are case reports and are limited in the number of participants. Larger sample size and homogeneous clinical variables have not been established. There is insufficient evidence to support the use of ECT in this subpopulation.

BIPOLAR DISORDER

Bipolar depression is depression that occurs as part of bipolar disorder or schizoaffective disorder. Accurate diagnostic workup to distinguish unipolar from bipolar depression is significant, as treatment strategies differ (Hirschfeld, 2014).

For bipolar disorder, evidence demonstrates a net benefit, but of less than moderate certainty, and may consist of a consensus opinion of experts, case studies, and common standard care. A systematic review and meta-analysis (19 studies, 2422 patients) of ECT for adults with treatment-refractory bipolar depression and unipolar depression found treatment response rates (decrease of symptoms by 50% or more) to ECT were statistically higher in bipolar depression versus unipolar depression (77.1% vs 74.2%, respectively). Remission rates were comparable between bipolar and unipolar depression at 52.3%. Limitations included inpatient patient populations and varying definitions of treatment resistance (Bahji et al., 2019). An observational study of ECT in 522 individuals with drug-resistant bipolar disorder found that 68% of individuals with bipolar depression responded to treatment, 73% of individuals in mixed state responded, 75% of individuals with mania responded, and the highest response rate was for those with catatonic features (81%) (Perugi et al., 2017). Although therapeutic trials for treatment-resistant bipolar disorder are uncommon, ECT is used for treatment of bipolar disorder, especially in more severe or refractory cases (Grunze et al., 2013; Versiani et al., 2011; Poon et al., 2012; Perugi et al., 2017).

CATATONIA

Catatonia may be characterized by the following (Luchini et al., 2015; American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 5th ed. 2013; American Psychiatric Association, Practice Guideline for the Treatment of Patients with Major Depressive Disorder [Third Edition]; 2010):

Motoric immobility, including stupor, catalepsy, or waxy flexibility
Peculiarities of voluntary movement such as posturing, stereotyped movements, prominent mannerisms, or prominent grimacing
Excessive motor activity without apparent reason
Involuntary repetition of another's actions or verbalizations
Negativism demonstrated by motiveless resistance to instruction
Mutism

For catatonia that is caused by a medical condition, the causative medical condition should be treated. However, if catatonia persists despite treatment of the underlying medical condition or treatment of the medical condition is not successful, then electroconvulsive therapy may be appropriate (Luchini et al., 2015). Response rates to ECT for the treatment of catatonia range from 80% to 100% and are superior to any other treatment (Luchini et al., 2015).

Malignant catatonia refers to a catatonic state that is accompanied by high fever, rigidity, autonomic nervous system instability (e.g., labile or high blood pressure, tachycardia, tachypnea, diaphoresis), and at times delirium, and can cause respiratory failure, coma, and death. ECT is the treatment of choice for malignant catatonia (Sienaert et al., 2014).

DEMENTIA-ASSOCIATED AGITATION AND AGGRESSION

For dementia-associated agitation and aggression, evidence is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit versus harm; additional research is recommended. A systematic review of the effectiveness of ECT for treatment of agitation in individuals with dementia found 11 studies (case reports, case series, retrospective chart review, retrospective case control, open-label prospective study) with a total of 216 individuals. Although maintenance ECT was found to show promising results in decreasing agitation, the studies were limited by use of concomitant psychotropic medications, inconsistent use of objective rating scales, short follow-up, lack of a control group, small sample sizes, and publication bias. The authors recommended that additional prospective studies are needed to validate these findings (Glass, et al. 2017). An observational study of 16 individuals with dementia found that ECT was associated with an improvement in agitation scores and function in response to treatment, but not overall psychological, social, and occupational functioning (Ujkaj et al., 2012).

MAJOR DEPRESSIVE DISORDER (UNIPOLAR DISORDER)

Major depressive disorder (unipolar disorder) refers to depression that occurs in the absence of bipolar disorder or schizoaffective disorder. Accurate diagnostic workup to distinguish unipolar from bipolar disorder is significant, as treatment strategies differ (Hirschfeld, 2014).

For major depressive disorder, evidence demonstrates at least moderate certainty of at least moderate net benefit. Major American and European guidelines indicate that ECT is appropriate for treatment of severe or treatment-resistant disease (McClintock et al., 2011; Vieta and Colom, 2011) ECT may be especially effective for those with psychotic depression or depression with prominent suicidal ideation (Allan and Ebmeier, 2011; Nordenskjöld et al., 2012). A systematic review found that short-term response rates for treatment-resistant depression range from 50% to 80% (Allan and Ebmeier, 2011; Nordenskjöldet al., 2012). Continuation of pharmacologic agents after ECT significantly reduces the relapse rate (Allan and Ebmeier, 2011). Use of ECT among psychiatric inpatients with severe affective disorders may be associated with reduced short-term psychiatric inpatient readmissions (Slade et al., 2017).

NEUROLEPTIC MALIGNANT SYNDROME

Neuroleptic malignant syndrome develops over several days to weeks and is caused by neuroleptic medications, which include typical antipsychotics, atypical antipsychotics, and certain dopamine receptor blocking agents. This condition is potentially dangerous and may be fatal. It requires immediate medical attention. Findings may include fever, muscular rigidity, lethargy, coma, stupor, confusion, delirium, incoherence, agitation, diaphoresis, leukocytosis, elevated liver function tests (LFTs) or creatine phosphokinase (CPK), metabolic acidosis, or autonomic instability with rapidly alternating vital signs (Paden et al., 2013; Berman, 2011).

Treatment of neuroleptic malignant syndrome consists of stopping the antipsychotic medication plus initiating supportive medical measures such as fluids and fever reduction. Medication is sometimes also used, most commonly benzodiazepines, dantrolene, bromocriptine, or amantadine. Severe cases require management in an intensive care unit (ICU). Most cases resolve in 1 to 2 weeks. Cases that do not resolve with these measures often respond to six to 10 ECT treatments.

Occasionally, individuals develop residual catatonic or parkinsonian-like symptoms after otherwise recovering from neuroleptic malignant syndrome. These symptoms can continue unabated for weeks if not treated with ECT. Six to 10 ECT treatments are usually sufficient for resolution.

PARKINSON'S DISEASE

For Parkinson's disease, evidence is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit versus harm; additional research is recommended. A systematic review and meta-analysis of five randomized controlled trials (49 individuals) examined the use of ECT in individuals with Parkinson's disease and was unable to conclude that a benefit in motor dysfunction was demonstrated due to the small number of studies (Fregni et al., 2005).

Although ECT has been used for years in the treatment of Parkinson's disease, it has never gained acceptance as treatment of refractory disease. Most studies are observational studies that show improvement in motor function but results across studies are inconsistent, as are the ECT methods used (Rosenquist et al., 2018).

PSYCHIATRIC MEDICATIONS

Classes of antidepressant medications include:

Selective serotonin reuptake inhibitors (SSRIs)
Serotonin norepinephrine reuptake inhibitors (SNRIs)
Tricyclic antidepressants (TCAs)
Tetracyclic antidepressants
Serotonin modulators
Norepinephrine serotonin modulators
Norepinephrine dopamine reuptake inhibitors
Monamine oxidase inhibitors (MAOIs)

ECT is appropriate for individuals whose symptoms are considered treatment resistant to antidepressant medications (Kumar et al., 2016; Rhebergen et al., 2015; Song et al., 2015; Spaans et al., 2015). Symptoms unresponsive to a trial of at least two different antidepressant medications from at least two different classes are considered treatment resistant.

There is currently no universally accepted definition of “treatment-resistant” for many psychiatric disorders (Trevino et al., 2014; Berlim and Turecki, 2007). Symptoms refractory to a trial of at least two different medications from at least two different classes are considered treatment resistant. Evidence in the medical literature to support the efficacy and effectiveness of interventions or services to address treatment-resistant disorders is absent, mixed, or unclear. Interventions reflect current best practice and is the product of an iterative process involving multiple clinicians with diverse expertise in varied practice and geographic settings.

Medications with established efficacy and effectiveness for adult and adolescent bipolar depression are lamotrigine, lithium, lurasidone, olanzapine-fluoxetine combination, and quetiapine regular or extended release (McInerney and Kennedy, 2014; Geddes et al., 2009; Calabrese et al., 2005). Although antidepressants are frequently prescribed for bipolar depression, available evidence indicates that antidepressants have little efficacy in the treatment of bipolar depression and may precipitate hypomania or mania if prescribed in the absence of a mood stabilizer (Nierenberg et al., 2015; Altshuler et al., 2006; Leverich et al., 2006). Short-term ECT has shown better efficacy compared to pharmacotherapy in inducing remission in patients with treatment resistant bipolar depression, with autobiographable amnesia reported, but no other loss of cognitive function (Nordenskjöld, 2015; Schoeyen et al., 2015; Kessler et al., 2014).

First-trimester pregnancy, Parkinson′s disease, dementia, and neuroleptic malignant syndrome (NMS) are examples of medical conditions that may contraindicate certain classes of psychiatric medication. A history of NMS or other adverse reactions to medications, including allergies, may also rule out their use. Comorbid medical conditions are common within the geriatric population, often necessitating the need for multiple condition-related medications, which may cause adverse interactions with psychotropic drugs. In addition, poor tolerance to these drugs and risk of toxicity may make ECT the preferred and safest first-line treatment for this population (Spaans et al., 2015; Kerner and Prudic, 2014; Riva-Posse et al., 2013; Birkenhäger et al., 2010).

ECT may also be a first-line treatment for adults and adolescents whose symptoms require a rapid response when a delay until medication becomes effective poses a high risk of morbidity or mortality (Lima et al., 2013; Rothschild , 2013; Leadholm et al., 2013; Baghai and Möller, 2008).

SCHIZOPHRENIA AND SCHIZOAFFECTIVE DISORDERS

For schizophrenia and schizoaffective disorders, evidence demonstrates at least moderate certainty of at least moderate net benefit. A systematic review and meta-analysis of 15 randomized controlled trials (1285 patients) evaluating the efficacy of ECT for treatment-resistant schizophrenia found moderate-quality evidence that ECT combined with standard care (antipsychotic medication) resulted in a clinically significant medium-term response as compared with standard care alone; lower quality evidence suggested improvements in general mental state and symptoms (e.g., anxiety, depression, thought disturbance) along with an increased risk of memory disturbances. The authors recommended further longer term prospective studies (Sinclair et al., 2019). A systematic review studying the use of ECT for treatment of schizophrenia identified 26 trials and concluded that ECT combined with antipsychotic medications may be considered when rapid global improvement and symptom reduction is needed, or in individuals who have had limited response to medication therapy alone (Tharyan and Adams, 2005). A retrospective matched-cohort study of 2074 patient pairs hospitalized with schizophrenia compared outcomes in individuals who underwent inpatient ECT with those who did not and found, at 1-year follow-up, that ECT was associated with decreased rehospitalization rates (Lin et al., 2018). A guideline on the treatment of schizophrenia indicates that ECT may be recommended in individuals with severe depression or suicidal behavior (Hasan et al., 2015). ECT also may be used in the treatment of catatonia (Consoli et al., 2010; Luchini et al., 2015; Puffer et al., 2016).

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Lin H-T, Liu S-K, Hsieh MH, et al. Impacts of electroconvulsive therapy on 1-year outcomes in patients with schizophrenia: a controlled, population-based mirror-image study. Schizophr Bull. 2018;44(4):798-806.

Lisanby SH. Electroconvulsive therapy for depression. N Engl J Med. 2007;357(19):1939-1945.

Luchini F, Medda P, Mariani MG, et al. Electroconvulsive therapy in catatonic patients: efficacy and predictors of response. World J Psychiatry. 2015;5(2):182-192.

Maletzky BM. Conventional and multiple-monitored electroconvulsive therapy. A comparison in major depressive episodes. J Nerv Ment Dis. 1986;174(5):257-264.

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McClintock SM, Choi J, Deng ZD, et al. Multifactorial determinants of the neurocognitive effects of electroconvulsive therapy. J ECT. 2014;30(2):165-176.

McInerney SJ, Kennedy SH. Review of evidence for use of antidepressants in bipolar depression. Prim Care Companion CNS Disord. 2014;16(5):10.4088/PCC.14r01653.

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Nierenberg AA, McIntyre RS, Sachs GS. Improving outcomes in patients with bipolar depression: a comprehensive review. J Clin Psychiatry. 2015;76(3):e10.

Nordenskjöld A. ECT is superior to pharmacotherapy for the short-term treatment of medication-resistant inpatients with bipolar depression. Evid Based Ment Health. 2015;18(4):118.

Nordenskjöld A, von Knorring L, Engström I. Predictors of the short-term responder rate of electroconvulsive therapy in depressive disorders--a population based study. BMC Psychiatry. 2012;12:115.

Paden MS, Franjic L, Halcomb SE. Hyperthermia caused by drug interactions and adverse reactions. Emerg Med Clin North Am. 2013;31(4):1035-1044.

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Petrides G, Malur C, Braga RJ, et al. Electroconvulsive therapy augmentation in clozapine-resistant schizophrenia: a prospective, randomized study. Am J Psychiatry. 2015;172(1):52-58.

Petrides G, Tobias KG, Kellner CH, et al. Continuation and maintenance electroconvulsive therapy for mood disorders: review of the literature. Neuropsychobiology. 2011;64(3):129-140.

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.

Poon SH, Sim K, Sum MY, et al. Evidence-based options for treatment-resistant adult bipolar disorder patients. Bipolar Disord. 2012;14(6):573-584.

Puffer CC, Wall CA, Huxsahl JE, et al. A 20 year practice review of electroconvulsive therapy for adolescents. J Child Adolesc Psychopharmacol. 2016;26(7):632-636.

Rapinesi C, et al. Prevention of relapse with maintenance electroconvulsive therapy in elderly patients with major depressive episode. J ECT. 2013;29(1):61-64.

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Ray-Griffith SL, Coker JL, Rabie N, et al. Pregnancy and electroconvulsive therapy: a multidisciplinary approach. J ECT. 2016;32(2):104-112.

Ren J, Li H, Palaniyappan L, et al. Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for major depression: a systematic review and meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2014;51:181-189.

Rhebergen D, Huisman A, Bouckaert F, et al. Older age is associated with rapid remission of depression after electroconvulsive therapy: a latent class growth analysis. Am J Geriatr Psychiatry. 2015;23(3):274-282.

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Roemer RA, Dubin WR, Jaffe R, et al. An efficacy study of single- versus double-seizure induction with ECT in major depression. J Clin Psychiatry. 1990;51(11):473-478.

Rosenquist PB, Youssef NA, Surya S, et al. When all else fails: the use of electroconvulsive therapy for conditions other than major depressive episode. Psychiatr Clin North Am. 2018;41(3):355-371.

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Schoeyen HK, Kessler U, Andreassen OA, et al. Treatment-resistant bipolar depression: a randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment. Am J Psychiatry. 2015;172(1):41-51.

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Coding

CPT Procedure Code Number(s)

90870

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

F20.0	Paranoid schizophrenia
F20.1	Disorganized schizophrenia
F20.2	Catatonic schizophrenia
F20.3	Undifferentiated schizophrenia
F20.5	Residual schizophrenia
F20.89	Other schizophrenia
F20.9	Schizophrenia, unspecified
F25.0	Schizoaffective disorder, bipolar type
F25.1	Schizoaffective disorder, depressive type
F25.8	Other schizoaffective disorders
F25.9	Schizoaffective disorder, unspecified
F31.0	Bipolar disorder, current episode hypomanic
F31.10	Bipolar disorder, current episode manic without psychotic features, unspecified
F31.11	Bipolar disorder, current episode manic without psychotic features, mild
F31.12	Bipolar disorder, current episode manic without psychotic features, moderate
F31.13	Bipolar disorder, current episode manic without psychotic features, severe
F31.2	Bipolar disorder, current episode manic severe with psychotic features
F31.30	Bipolar disorder, current episode depressed, mild or moderate severity, unspecified
F31.31	Bipolar disorder, current episode depressed, mild
F31.32	Bipolar disorder, current episode depressed, moderate
F31.4	Bipolar disorder, current episode depressed, severe, without psychotic features
F31.5	Bipolar disorder, current episode depressed, severe, with psychotic features
F31.60	Bipolar disorder, current episode mixed, unspecified
F31.61	Bipolar disorder, current episode mixed, mild
F31.62	Bipolar disorder, current episode mixed, moderate
F31.63	Bipolar disorder, current episode mixed, severe, without psychotic features
F31.64	Bipolar disorder, current episode mixed, severe, with psychotic features
F31.70	Bipolar disorder, currently in remission, most recent episode unspecified
F31.71	Bipolar disorder, in partial remission, most recent episode hypomanic
F31.72	Bipolar disorder, in full remission, most recent episode hypomanic
F31.73	Bipolar disorder, in partial remission, most recent episode manic
F31.74	Bipolar disorder, in full remission, most recent episode manic
F31.75	Bipolar disorder, in partial remission, most recent episode depressed
F31.76	Bipolar disorder, in full remission, most recent episode depressed
F31.77	Bipolar disorder, in partial remission, most recent episode mixed
F31.78	Bipolar disorder, in full remission, most recent episode mixed
F31.81	Bipolar II disorder
F31.89	Other bipolar disorder
F31.9	Bipolar disorder, unspecified
F32.0	Major depressive disorder, single episode, mild
F32.1	Major depressive disorder, single episode, moderate
F32.2	Major depressive disorder, single episode, severe without psychotic features
F32.3	Major depressive disorder, single episode, severe with psychotic features
F32.4	Major depressive disorder, single episode, in partial remission
F32.5	Major depressive disorder, single episode, in full remission
F32.9	Major depressive disorder, single episode, unspecified
F33.0	Major depressive disorder, recurrent, mild
F33.1	Major depressive disorder, recurrent, moderate
F33.2	Major depressive disorder, recurrent severe without psychotic features
F33.3	Major depressive disorder, recurrent, severe with psychotic symptoms
F33.40	Major depressive disorder, recurrent, in remission, unspecified
F33.41	Major depressive disorder, recurrent, in partial remission
F33.42	Major depressive disorder, recurrent, in full remission
F33.9	Major depressive disorder, recurrent, unspecified

EXPERIMENTAL/INVESTIGATIONAL

F01.51	Vascular dementia with behavioral disturbance
F02.811	Dementia in other diseases classified elsewhere, unspecified severity, with agitation
F02.818	Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance
F02.82	Dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance
F02.83	Dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance
F02.84	Dementia in other diseases classified elsewhere, unspecified severity, with anxiety
F02.A0	Dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F02.A11	Dementia in other diseases classified elsewhere, mild, with agitation
F02.A18	Dementia in other diseases classified elsewhere, mild, with other behavioral disturbance
F02.A2	Dementia in other diseases classified elsewhere, mild, with psychotic disturbance
F02.A3	Dementia in other diseases classified elsewhere, mild, with mood disturbance
F02.A4	Dementia in other diseases classified elsewhere, mild, with anxiety
F02.B0	Dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F02.B11	Dementia in other diseases classified elsewhere, moderate, with agitation
F02.B18	Dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance
F02.B2	Dementia in other diseases classified elsewhere, moderate, with psychotic disturbance
F02.B3	Dementia in other diseases classified elsewhere, moderate, with mood disturbance
F02.B4	Dementia in other diseases classified elsewhere, moderate, with anxiety
F02.C0	Dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F02.C11	Dementia in other diseases classified elsewhere, severe, with agitation
F02.C18	Dementia in other diseases classified elsewhere, severe, with other behavioral disturbance
F02.C2	Dementia in other diseases classified elsewhere, severe, with psychotic disturbance
F02.C3	Dementia in other diseases classified elsewhere, severe, with mood disturbance
F02.C4	Dementia in other diseases classified elsewhere, severe, with anxiety
F03.911	Unspecified dementia, unspecified severity, with agitation
F03.918	Unspecified dementia, unspecified severity, with other behavioral disturbance
F03.92	Unspecified dementia, unspecified severity, with psychotic disturbance
F03.93	Unspecified dementia, unspecified severity, with mood disturbance
F03.94	Unspecified dementia, unspecified severity, with anxiety
F03.A0	Unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F03.A11	Unspecified dementia, mild, with agitation
F03.A18	Unspecified dementia, mild, with other behavioral disturbance
F03.A2	Unspecified dementia, mild, with psychotic disturbance
F03.A3	Unspecified dementia, mild, with mood disturbance
F03.A4	Unspecified dementia, mild, with anxiety
F03.B0	Unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F03.B11	Unspecified dementia, moderate, with agitation
F03.B18	Unspecified dementia, moderate, with other behavioral disturbance
F03.B2	Unspecified dementia, moderate, with psychotic disturbance
F03.B3	Unspecified dementia, moderate, with mood disturbance
F03.B4	Unspecified dementia, moderate, with anxiety
F03.C0	Unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F03.C11	Unspecified dementia, severe, with agitation
F03.C18	Unspecified dementia, severe, with other behavioral disturbance
F03.C2	Unspecified dementia, severe, with psychotic disturbance
F03.C3	Unspecified dementia, severe, with mood disturbance
F03.C4	Unspecified dementia, severe, with anxiety
F84.0	Autistic disorder
G20.A1	Parkinson's disease without dyskinesia, without mention of fluctuations
G20.A2	Parkinson's disease without dyskinesia, with fluctuations
G20.B1	Parkinson's disease with dyskinesia, without mention of fluctuations
G20.B2	Parkinson's disease with dyskinesia, with fluctuations
G20.C	Parkinsonism, unspecified
G31.09	Other frontotemporal dementia
G31.83	Dementia with Lewy bodies

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA14.001a:

10/18/2023

The policy has been reviewed and reissued to communicate the Company’s continuing position on Electroconvulsive Therapy (ECT).

10/01/2023

This version of the policy will become effective 10/01/2023.

The following ICD-10 CM codes have been added to this policy as experimental/investigational: G20.A1, G20.A2, G20.B1, G20.B2, G20.C.

The following ICD-10 diagnosis code has been removed from this policy: G20.

Revisions From MA14.001:

01/01/2023

This version of the policy will become effective 01/01/2023. The following new policy has been developed to address coverage criteria for Electroconvulsive Therapy (ECT).

Version Effective Date:

10/1/2023

Version Issued Date:

9/29/2023

Version Reissued Date:

10/18/2023