00104
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- - "Member prefers ECT as a treatment option in consultation with the psychiatrist" — documentation of informed patient preference after psychiatrist consultation.
- Pre-procedure documentation typically implied by the policy/background: psychiatric assessment/diagnosis, informed consent, anesthesiology/anesthesia risk assessment and clearance, and clinical notes supporting indication and planned ECT course (number/frequency).
- For prophylactic/maintenance ECT: documentation of prior acute response and rationale for maintenance scheduling (frequency, plan to taper), and prior medication intolerance or failure if applicable.
- If used for non-standard/limited evidence indications (e.g., autoimmune encephalitis, refractory status epilepticus, dementia agitation), documentation of prior standard treatments tried, details of multidisciplinary discussion, and risk-benefit rationale.
Key Coverage Criteria
- Schizoaffective disorder (F25.0–F25.9)
- Major depressive disorder (unipolar disorder) (F32.0–F33.9)
- Tourette syndrome (emerging treatment strategies mentioned)
- Catatonia (F06.1)
- Nondepressed psychiatric illness in elderly patients (efficacy/tolerability review)
- Refractory status epilepticus (ECT for refractory status epilepticus — systematic review cited)
3 Active Policies
AETNA-CPB-0445 — Electroconvulsive Therapy
ANTHEM-CG-MED-21 — CG-MED-21 Anesthesia Services and Moderate (âConsciousâ) Sedation
ANTHEM-SURG.00104 — SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
Related Codes
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