MEDICAL NECESSITY CRITERIA Electroconvulsive Therapy

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MEDICAL NECESSITY CRITERIA
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) was introduced in 1938 and it is still a treatment frequently
chosen by practitioners for severe, debilitating mental disorders. In the past four decades
numerous clinical trials have confirmed the efficacy and clinical relevance of ECT, especially for
severe illnesses characterized by biological features or delusions. ECT is the treatment of choice
when Psychopharmacology has failed for severely depressed, manic or psychotic individuals.
ECT has a more rapid onset of action than antidepressant or antipsychotic pharmcotherapeutic
interventions making it a primary consideration for individuals whose symptomatology places
them or others at significant risk of harm. ECT should be strongly considered as a treatment
alternative when an individual presents with severe depression with psychotic features and active
suicidal behavior.
Research has shown that potential side-effects include memory loss, headaches, nausea, and
muscle stiffness. The current clinical and research literature contain a variety of conclusions
regarding the frequency, severity, and duration of cognitive side-effects. Retrograde memory loss
has been reported to last anywhere from 2 weeks to 7 months, while anterograde memory loss is
reported to recover rapidly.
Research has shown that bilateral titrated dosing at levels 1.5 – 2.5 times above the seizure
threshold is effective. Fewer cognitive side-effects have been observed in treatment schedules of
two-to three-times-weekly over the course of nine to twelve sessions. Research has shown that
unilateral non-dominant ECT yields less severe cognitive side-effects, as well as less effective
treatment.
Research suggests that the clinical condition of the patient should aid in determining ECT dosing
and frequency. For example, patients that present with imminent danger or harm to self or other
may require a more frequent dosing regimen.
The Electroconvulsive Therapy Criteria are intended to assist in making authorization decisions
for this treatment modality. When reviewing requests for ECT the following factors should be
considered:
1. Is the clinical condition one that is likely to respond to ECT?
2. What is the rationale for selecting ECT over other options? (Have other options failed, for
example, or is rapid onset of action a primary clinical concern?)
3. Do any contraindications to the use of ECT exist?
4. What level of care is required to safely treat the individual?
The level of care decision is separate from the decision to authorize ECT as a treatment
modality. Uncomplicated ECT can safely be provided in an ambulatory setting. Level of care
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decisions are based on the individual’s clinical condition, not on the choice of ECT as a
treatment modality. This set of criteria assists in making the determination of whether or not
ECT should be authorized, not level of care decisions.
In rare instances, ECT that was planned in an ambulatory setting may require inpatient admission
if the individual’s reaction to the treatment prevents safe discharge. For example, the individual
remains unusually confused many hours after completing treatment. This situation is not unlike
instances where surgical procedures are scheduled as outpatient procedures but the individual’s
post-procedure condition necessitates inpatient admission.
I. Treatment Initiation Criteria
The presence of one of the Treatment Initiation Criteria is indicative of the appropriateness of
Electroconvulsive Therapy.
A. The individual has a history of a mood disorder that has not responded well to adequate
trials of pharmacologic treatment and presents with signs and symptoms consistent with a
recurrent episode of a mood disorder.
B. The individual has been treated with ECT for a mood disorder in the past, is diagnosed
with a recurrent episode of a mood disorder, and prefers ECT to pharmacologic
treatment.
C. The individual is diagnosed with a mood disorder that has not responded to adequate
trials of pharmacologic treatment.
D. The individual presents with a mood disorder resulting in behaviors that put the
individual or others at significant risk of harm (such as that resulting from acting on
suicidal or paranoid ideation) that need to be ameliorated as quickly as possible.
E. The individual presents with severe Mania resulting in behaviors that put the individual
or others at significant risk of harm (such as that resulting from exhaustion or physically
harming others) not responsive to pharmacologic intervention.
F. The individual presents with chronic or recurrent aggression not responsive to
pharmcotherapeutic intervention.
G. The individual presents with Schizophrenia with affective or catatonic symptoms not
responsive to pharmacologic intervention.
H. The individual presents with Schizophrenia with affective symptoms resulting in
behaviors that put the individual or others at significant risk of harm (such as that
resulting from acting on suicidal or paranoid ideation) that need to be ameliorated as
quickly as possible.
I. The individual presents with Catatonia not responsive to pharmacologic intervention.
J. The individual, especially an older adult, is not able to tolerate the side effects of
pharmacologic agents (for example cardiovascular, genitourinary, or central nervous
system side effects).
K. The individual is pregnant and the safety of the fetus from pharmacologic intervention is
a significant concern.
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II. Exclusionary Criteria
The patient had a complete medical assessment to exclude contraindications, such as:
A. The individual has an intracranial space occupying lesion with increased intracranial
pressure.
B. The individual has had a cerebrovascular accident within the last month.
C. The individual has a bleeding or unstable vascular aneurism or abnormality.
D. The individual has a retinal detachment.
E. The individual has a significant and unstable cardiovascular problem including recent
myocardial infarction, severe cardiac ischemia, and significant hypertension (including
pheochromocytoma).
III. Treatment Continuation Criteria
The presence of one of the following Treatment Continuation Criteria is required throughout the
ECT treatment episode.
A. The individual has had an initial positive response to ECT and completion of a course of
treatment is clinically indicated. A typical course of ECT for treatment of a mood
disorder is 2 to 3 times weekly administered over 9 to 12 sessions.
B. The individual was successfully treated with ECT for a mood disorder and maintenance
treatment with ECT is indicated because of one of the following:
1. The individual has not responded favorably to adequate trials of antidepressant
medications or mood stabilizers in the past.
2. The individual has had reoccurrences of a mood disorder while taking adequate
dosages of maintenance antidepressant medications or mood stabilizers.
3. Antidepressant medications or mood stabilizers are medically contraindicated.
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