Aetna considers electroconvulsive therapy (ECT) medically necessary for members diagnosed with any of the following conditions.
Certain acute schizophrenic exacerbations, or
Major depression (unipolar, bipolar, or mixed episode), or
Note: More than 20 sessions of ECT in a treatment series is rarely medically necessary.
Aetna considers multiple monitored ECT experimental and investigational because its effectiveness has not been established.
Aetna considers ultrabrief bilateral ECT experimental and investigational because its effectiveness has not been established.
Aetna considers ECT experimental and investigational for the treatment of the following interventions because its effectiveness for these indications has not been established (not an all inclusive list):
Electroconvulsive therapy (ECT, also known as electroshock therapy) involves the intentional induction of generalized seizures by administering electrical impulses to the anesthetized patient. Treatments are typically administered by a psychiatrist and an anesthesiologist or anesthetist.
Electroconvulsive therapy is generally administered in an inpatient setting, but can be administered on an outpatient basis in a facility with treatment and recovery rooms. It is usually administered 2 or 3 times a week, although ECT may be administered daily if tolerated.
The primary indication for ECT is major depressive disorder. Electroconvulsive therapy is usually considered when medications fail, can not 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, life-threatening inanition, psychosis, or stupor. The average course of treatment for depression is 6 to 12 treatments, but some patients may require as many as 20 treatments.
Electroconvulsive therapy has been found to be as or more effective than lithium in the treatment of manic episodes and is also a potential treatment for patients experiencing mixed episodes. It 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, is preferred by the patient in consultation with the psychiatrist, 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.
Electroconvulsive therapy 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, the American Psychiatric Association (APA) (1999) 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.”
A few clinicians have reported the successful use of ECT in severe obsessive-compulsive disorder (OCD), anorexia nervosa, atypical psychosis, cycloid psychosis, epilepsy with alternating psychosis, and chronic pain disorder, but those disorders are not usually considered indications for ECT. Electroconvulsive therapy is not an effective treatment for body dysmorphic disoder, dysthymic disorder, neuroses, dissociative disorders, hypochondriasis, conversion disorder, substance-related disorders, and personality disorders. Dell'Osso and colleagues (2005) noted that in addition to pharmacological, behavioral, and neurosurgical interventions, different brain stimulation methods such as transcranial magnetic stimulation, deep brain stimulation, as well as ECT have been examined 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. Furthermore, none of the mentioned treatments has received approval for the treatment of OCD from the Food and Drug Administration. This is in agreement with the observation of Schruers et al (2005) who stated that serotonin reuptake inhibitors augmentation strategies with a variety of drugs and ECT have demonstrated results in individual cases, but no conclusive evidence has been found in placebo-controlled trials. In addition, the National Institute for Health and Clinical Excellence (NICE, 2006) guidelines on OCD stated that there is insufficient evidence on which to base a recommendation for the use of ECT in the treatment of OCD, especially given potential associated risks with ECT. Furthermore, the NICE report stated that there is no evidence that ECT or psychosurgery is beneficial in treating patients with body dysmorphic disorder.
Clinical experience suggests that ECT be continued until the patient has shown a maximal response; there is no evidence that administering 1 or 2 additional treatments results in a better outcome. Indeed, increased confusion from additional treatments may produce clinical deterioration. Electroconvulsive therapy is discontinued in patients who have had a partial but substantial improvement but show no change after 2 more treatments and in patients who have not responded at all after 6 to 10 treatments.
Prophylactic ECT may be needed for patients who do not tolerate or respond to prophylactic medications or who respond better to ECT. After remission, prophylactic ECT treatments are initially administered at weekly intervals, and the frequency of treatments is usually decreased gradually to once a month or less. Treatment has been continued for periods of 4 or 6 months to five years or longer; some patients apparently require indefinite prophylactic ECT.
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 a significant medical illness in which risk outweighs potential benefit.
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. 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…”.
In an open, prospective study, Margoob et al (2010) examined the effects of ECT in the treatment of patients with chronic, severe, antidepressant- and congitive behavioral therapy (CBT)-refractory post-traumatic stress disorder (PTSD). A total of 20 consenting adults were prospectively treated with a fixed course of 6 bilateral ECT treatments administered on an outpatient basis at a twice-weekly frequency. The primary outcome measure was improvement on the Clinician-Administered Post-traumatic Stress Disorder Scale (CAPS). Baseline refractoriness was defined as a failure to respond to an adequate course of at least 4 different antidepressant drugs along with 12 sessions of CBT. Response to ECT was defined as at least 30 % attenuation of CAPS ratings, and remission as an end point CAPS score of 20 or less. After ECT, patients were prescribed sertraline (100 to 150 mg/day) or mirtazapine (15 to 30 mg/day). All but 3 patients completed the ECT course. An intent-to-treat analysis (n = 20) showed statistically and clinically significant improvement in the sample as a whole: CAPS scores decreased by a mean of 34.4 %, and depression scores by a mean of 51.1 %. Most of the improvement in CAPS and depression ratings developed by the third ECT; that is, by day 10 of treatment, itself. The improvement in CAPS ratings was independent of the improvement in depression ratings; and improvement in CAPS did not differ significantly between patients with less severe versus more severe baseline depression. The response rate was 70 %; no patient remitted. In the completer analysis (n = 17), mean improvements were 40 % and 57 % for CAPS and depression ratings, respectively, and the response rate was 82 %. Treatment gains were maintained at a 4 to 6 month follow-up. The authors concluded that ECT may improve the core symptoms of PTSD independently of improvement in depression, and may therefore be a useful treatment option for patients with severe, chronic, medication- and CBT-refractory PTSD. The findings of this small study need to be validated by well-designed studies.
Ujkaj et al (2012) examined the safety and effectiveness of ECT for agitation and aggression in dementia patients. A total of 16 patients with a diagnosis of dementia treated with ECT for agitation/aggression during 2004 to 2007 were included in this analysis. Clinical charts were rated on the Pittsburgh Agitation Scale as the primary outcome; the Clinical Global Impression scale and the Global Assessment of Functioning pre- and post-ECT were also used. 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 1 patient, in whom ECT was discontinued following 11 bilateral treatments, showed no improvement; 8 patients showed transient postictal confusion, which typically resolved within 48 hours. Two patients showed more severe postictal confusion that required modification of treatment. The authors concluded that these results suggested that ECT is an effective and safe treatment for agitation and aggression in dementia. Moreover, they stated that further prospective studies are warranted.
Oudman (2012) noted 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 over-looked treatment option in the elderly with dementia and depression. The aim of this review was to provide a critical analysis of the safety and effectiveness of ECT in depression super-imposed 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 non-vascular origin. Some studies do suggest that cognitive side effects are likely in later stages of dementia and in patients with vascular dementia. The author concluded that it is therefore of crucial relevance to prospectively study effects of ECT in different types and phases of dementia in controlled trials.
Loo and colleagues (2012) noted that the effect of shortening the pulse width of the electrical stimulus when administering ECT has recently been systematically studied with promising results. These investigators examined outcomes from 3 randomized controlled trials that compared ultrabrief (less than or equal to 0.3 ms) with brief (0.5 to 1.5 ms) pulse width ECT, and other recent clinical trials of ultrabrief pulse width ECT. The emerging evidence for ultrabrief pulse right unilateral (RUL) ECT suggested clinically meaningful efficacy and substantially reduced neuropsychological side effects compared with standard (brief) pulse ECT; this may represent a generational advance in the ECT technique. However, it is unclear if patients receiving ultrabrief pulse RUL ECT may have a slower speed of response and require additional treatments compared with brief pulse ECT. Therefore, until further data are available, clinicians may be well advised to use brief pulse ECT in situations requiring an urgent clinical response. The authors concluded that the evidence base for ultrabrief bilateral ECT is limited, with findings that efficacy may be reduced compared with brief pulse width ECT. They stated that ultrabrief bilateral ECT should not be used outside the research setting.
Lima et al (2013) reviewed the recent and classical aspects regarding ECT use in adolescents. These researchers performed a systematic review that conformed to the PRISMA statement. From the 212 retrieved articles, only 39 were included in the final sample. The reviewed studies brought indications of ECT use in adolescents, evaluated the efficiency of this therapy regarding remission, and explored the potential risks and complications of the procedure. The authors concluded that the use of ECT in adolescents is considered a highly efficient option for treating several psychiatric disorders, achieving high remission rates, and presenting few and relatively benign adverse effects. Risks can be mitigated by the correct use of the technique and are considered minimal when compared to the efficiency of ECT in treating psychopathologies.
Leiknes et al (2013) explored practice, use, and risk of ECT in pregnancy. These investigators performed a systematic search using the databases Medline, Embase, PsycINFO, SveMed and CINAHL (EBSCO). Only primary data-based studies reporting ECT undertaken during pregnancy were included. Two reviewers independently checked study titles and abstracts according to inclusion criteria and extracted detailed use, practice, and adverse effects data from full text retrieved articles. Studies and extracted data were sorted according to before and after year 1970, due to changes in ECT administration over time. A total of 67 case reports were included and studies from all continents represented. Altogether, 169 pregnant women were identified, treated during pregnancy with a mean number of 9.4 ECTs, at mean age of 29 years. Most women received ECT during the 2nd trimester and many were Para I. Main diagnostic indication in years 1970 to 2013 was depression/bipolar disorder (including psychotic depression). Missing data on fetus/child was 12 %. Electroconvulsive therapy parameter report was often sparse. Both bilateral and unilateral electrode placement was used and thiopental was the main anesthetic agent. Adverse events such as fetal heart rate reduction, uterine contractions, and premature labor (born between 29 and 37 gestation weeks) were reported for nearly 1/3 (29 %) of the cases. The overall child mortality rate was 7.1 %. Lethal outcomes for the fetus and/or baby had diverse associations. The authors concluded that ECT during pregnancy is advised only as last resort treatment under very stringent diagnostic and clinical indications.
The American Academy of Neurology’s evidence-based guideline on “Treatment of tardive syndromes” (Bhidayasiri et al, 2013) stated that “Data are insufficient to determine the efficacy of electroconvulsive therapy for TDD [tardive dyskinesias] treatment”.
Selection Criteria for ECT:
Member has one of the qualifying psychiatric conditions listed in the policy section above; and
Member is at least 12 years of age; and
One of the following criteria is met:
Member is unresponsive to effective medications, given for adequate dose and duration, that are indicated for the member's condition (e.g., anti-depressants, anti-psychotics, etc., as appropriate); or
Member is unable to tolerate effective medications or has a medical condition for which medication is contraindicated; or
Member has had favorable responses to ECT in the past, or
Member is unable to safely wait until medication is effective (e.g., due to life-threatening inanition, psychosis, stupor, extreme agitation, high suicide or homicide risk, etc.); or
Member is experiencing severe mania or depression during pregnancy; or
Member prefers ECT as a treatment option in consultation with the psychiatrist.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
ICD-9 codes covered if selection criteria are met:
291.0 - 294.9
Organic psychotic conditions
295.00 - 299.91
Depressive disorder, not elsewhere classified
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
290.0 - 290.9
300.00 - 300.9
Anxiety, dissociative and somatoform disorders
301.0 - 301.9
303.00 - 305.93
Alcohol dependence syndrome, drug dependence, and nondependent abuse of drugs
Post-traumatic stress disorder
Subacute dyskinesia due to drugs
337.20 - 337.29
Reflex sympathetic dystrophy
Abnormal involuntary movements
The above policy is based on the following references:
American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder. Am J Psychiatry. 1994;151(12 Suppl):1-36.
American Psychiatric Association. Practice guideline for major depressive disorder in adults. Am J Psychiatry. 1993;150(4 Suppl):1-26.
American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry. 1997;154(4 Suppl):1-63.
Dubovsky SL. Electroconvulsive therapy. In: Comprehensive Textbook of Psychiatry. 6th ed. HI Kaplan and BJ Sadock, eds. Baltimore, MD: Williams & Wilkins; 1995:2129-2140.
American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156(5 Suppl):1-20.
McClellan J, Werry J; American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 1997;36 (10 Suppl):157S-176S.
American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 1998;37(10 Suppl):63S-83S.
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. Natl Inst Health Consens Dev Conf Consens Statement. 1985 June 10-12;5(11):1-23. Available at: http://consensus.nih.gov/cons/051/051_statement.htm. Accessed July 7, 2005.
U.S. Department of Health and Human Services, Office of the Inspector General. Medicare reimbursement for electroconvulsive therapy. OEI-12-01-00450. Washington, DC; U.S. Department of Health and Human Services; December 2001. Available at: http://oig.hhs.gov/oei/reports/oei-12-01-00450.pdf. Accessed July 7, 2005.
Abdulwadud O. Electro convulsive therapy (ECT) in the management of bipolar mood disorder during pregnancy. Evidence Centre Critical Appraisal. Clayton, VIC: Centre for Clinical Effectiveness (CCE); 2001.
Bauer M, Whybrow PC, Angst J, et al. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 2: Maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions. World J Biol Psychiatry. 2002;3(2):69-86.
Grunze H, Kasper S, Goodwin G, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of bipolar disorders. Part I: Treatment of bipolar depression. World J Biol Psychiatry. 2002;3(3):115-124.
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Grunze H, Kasper S, Goodwin G, et al. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders, Part II: Treatment of Mania. World J Biol Psychiatry. 2003;4(1):5-13.
National Institute for Clinical Excellence (NICE). Guidance on the use of electroconvulsive therapy. Technology Appraisal 59. London, UK: NICE; April 2003. Available at: http://www.nice.org.uk/Docref.asp?d=68306. Accessed February 4, 2004.
Geddes J, Carney S, Cowen P, et al. Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. Lancet. 2003;361(9360):799-808.
Kho KH, van Vreeswijk MF, Simpson S, Zwinderman AH. A meta-analysis of electroconvulsive therapy efficacy in depression. J ECT. 2003;19(3):139-147.
Lehman AF, Lieberman JA, Dixon LB, et al. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 2004;161(2 Suppl):1-56.
Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Multiple Electroconvulsive Therapy (MECT) (160.25). Medicare Coverage Database. Baltimore, MD: CMS; April 1, 2004.
Ellis P; Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression. Australian and New Zealand clinical practice guidelines for the treatment of depression. Aust N Z J Psychiatry. 2004;38(6):389-407.
Ghaziuddin N, Kutcher SP, Knapp P, et al. Practice parameter for use of electroconvulsive therapy with adolescents. J Am Acad Child Adolesc Psychiatry. 2004;43(12):1521-1539.
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American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder. Am J Psychiatry. 2002;159(4 Suppl):1-50.
Ciapparelli A, Dell'Osso L, Tundo A, et al. Electroconvulsive therapy in medication-nonresponsive patients with mixed mania and bipolar depression. J Clin Psychiatry. 2001;62(7):552-555.
Devanand DP, Polanco P, Cruz R, et al. The efficacy of ECT in mixed affective states. J ECT. 2000;16(1):32-37.
Gruber NP, Dilsaver SC, Shoaib AM, et al. ECT in mixed affective states: A case series. J ECT. 2000;16(2):183-188.
American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. Am J Psychiatry. 2000;157(4 Suppl):1-45.
Schruers K, Koning K, Luermans J, et al. Obsessive-compulsive disorder: A critical review of therapeutic perspectives. Acta Psychiatr Scand. 2005;111(4):261-271.
Dell'Osso B, Altamura AC, Allen A, Hollander E. Brain stimulation techniques in the treatment of obsessive-compulsive disorder: Current and future directions. CNS Spectr. 2005;10(12):966-979, 983.
Cybulska EM. Obsessive-compulsive disorder, the brain and electroconvulsive therapy. Br J Hosp Med (Lond). 2006;67(2):77-81.
National Institute for Health and Clinical Excellence (NICE). Obsessive compulsive disorder: Core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder. Clinical Practice Guideline No. 31. London, UK; NICE; January 25, 2006. Available at: http://www.nice.org.uk/page.aspx?o=289817. Accessed May 23, 2007.
McLoughlin DM, Mogg A, Eranti S, et al. The clinical effectiveness and cost of repetitive transcranial magnetic stimulation versus electroconvulsive therapy in severe depression: A multicentre pragmatic randomised controlled trial and economic analysis. Health Technol Assess. 2007;11(24):1-54.
Valentí M, Benabarre A, García-Amador M, et al. Electroconvulsive therapy in the treatment of mixed states in bipolar disorder. Eur Psychiatry. 2008;23(1):53-56.
Wilkins KM, Ostroff R, Tampi RR. Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: A review of the literature. J Geriatr Psychiatry Neurol. 2008;21(1):3-11.
Barbui C, Butler R, Ciprani A, et al. Depression in adults: Drug and physical treatments. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; April 2006.
Hazell P. Depression in children and adolescents (updated). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; April 2008.
Hackett ML, Anderson CS, House A, Xia J. Interventions for treating depression after stroke. Cochrane Database Syst Rev. 2008;(4):CD003437.
Rasmussen KG, Mueller M, Rummans TA, et al. Is baseline medication resistance associated with potential for relapse after successful remission of a depressive episode with ECT? Data from the Consortium for Research on Electroconvulsive Therapy (CORE). J Clin Psychiatry. 2009;70(2):232-237.
van Herck E, Sienaert P, Hagon A. Electroconvulsive therapy for patients with intracranial aneurysms: A case study and literature review. Tijdschr Psychiatr. 2009;51(1):43-51.
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Consoli A, Benmiloud M, Wachtel L, et al. Electroconvulsive therapy in adolescents with the catatonia syndrome: Efficacy and ethics. J ECT. 2010;26(4):259-265.
Margoob MA, Ali Z, Andrade C. Efficacy of ECT in chronic, severe, antidepressant- and CBT-refractory PTSD: An open, prospective study. Brain Stimul. 2010;3(1):28-35.
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;20(1):61-72.
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.
Dierckx B, Heijnen WT, van den Broek WW, Birkenhäger TK. Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: A meta-analysis. Bipolar Disord. 2012;14(2):146-150.
Loo CK, Katalinic N, Martin D, Schweitzer I. A review of ultrabrief pulse width electroconvulsive therapy. Ther Adv Chronic Dis. 2012;3(2):69-85.
Amanullah S, Delva N, McRae H, et al. Electroconvulsive therapy in patients with skull defects or metallic implants: A review of the literature and case report. Prim Care Companion CNS Disord. 2012;14(2).
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.
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Leiknes KA, Cooke MJ, Jarosch-von Schweder L, et al. Electroconvulsive therapy during pregnancy: A systematic review of case studies. Arch Womens Ment Health. 2013 Nov 24. [Epub ahead of print]
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.