Coverage Policies

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INDEX:



Effective Date: 07/13/2004	Title: Prolonged EEG Monitoring
Revision Date: 01/01/2020	Document: BI051:00
CPT Code(s): 95950, 95951, 95953, 95956, 95700, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above Revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Video EEG monitoring and prolonged EEG monitoring are covered when considered medically necessary. Preauthorization is required.
Medical Statement
1. Ambulatory Electroencephalographic Monitoring: Ambulatory EEG monitoring is considered medically necessary for any of the following conditions: I. Diagnosis of a seizure disorder (epilepsy) -- the member has episodes strongly suggestive of epilepsy and when history, examination, and routine EEG do not resolve the diagnosis uncertainties; or II. Classification of seizure type in members who have epilepsy poorly controlled -- only ictal recordings can reliably be used to classify seizure type (or types) which is important in selecting appropriate anti-epileptic drug therapy; or III. Localization of the epileptogenic region of the brain during pre-surgical evaluation -- to identify appropriate surgical candidates. Duration of Monitoring: The goal of ambulatory EEG is usually achieved within 48 hours. 2. Video Electroencephalographic (EEG) Monitoring I. Video EEG monitoring is considered medically necessary for the following indications, when the diagnosis cannot be made by neurologic examination, standard EEG studies, and non-neurologic causes of symptoms (e.g., syncope, cardiac arrhythmias) have been ruled out: A. To differentiate epileptic events from psychogenic seizures; or B. To establish the first diagnosis of epilepsy; or C. To establish the specific type of epilepsy in poorly characterized seizure types where such characterization is medically necessary to select the most appropriate therapeutic regimen. In addition, Video EEG monitoring may be considered medically necessary to establish the diagnosis of epilepsy in very young children. Note: Once the cause of seizures and specific type of epilepsy has been established, continued video EEG monitoring (e.g., for monitoring response to therapy or titrating medication dosages) is considered not medically necessary. In these cases, response to therapy can be assessed using standard EEG monitoring or ambulatory cassette EEG monitoring. II. Video EEG monitoring is medically necessary for identification and localization of a seizure focus in persons with intractable epilepsy who are being considered for surgery. III. Duration of Monitoring: The duration of video EEG monitoring that is considered medically necessary depends on the frequency of the person`s symptoms that are being investigated, and generally can be completed in 3 to 5 days. Continued monitoring will be reviewed on a day by day basis. Note: Most persons requiring video EEG monitoring do not require an acute level of care. Acute care may be appropriate for persons at high risk for status epilepticus with withdrawal of antiepileptic medications, sleep deprivation, or photic stimulation. Inpatient status for this purpose must be preauthorized. Codes Used In This BI: 95700 Electroencephalogram (EEG) continuous recording, with video when performed, setup, patient education, and takedown when performed, administered in person by EEG technologist, minimum of 8 channels 95705 Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; unmonitored 95706 … with intermittent monitoring and maintenance 95707 … with continuous, real-time monitoring and maintenance 95708 Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored 95709 … with intermittent monitoring and maintenance 95710 … with continuous, real-time monitoring and maintenance 95711 Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; unmonitored 95712 …. with intermittent monitoring and maintenance 95713 … with continuous, real-time monitoring and maintenance 95714 Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored 95715 … with intermittent monitoring and maintenance 95716 … with continuous, real-time monitoring and maintenance 95717 Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; without video 95718 … with video (VEEG) 95719 Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period; without video 95720 … with video (VEEG) 95721 Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, without video 95722 … greater than 36 hours, up to 60 hours of EEG recording, with video (VEEG) 95723 … greater than 60 hours, up to 84 hours of EEG recording, without video 95724 … greater than 60 hours, up to 84 hours of EEG recording, with video (VEEG) 95725 … greater than 84 hours of EEG recording, without video 95726 … greater than 84 hours of EEG recording, with video (VEEG) 95950 prolonged EEG monitoring (code deleted eff 01/01/2020) 95951 Video EEG monitoring (code deleted eff 01/01/2020) 95953 prolonged EEG monitoring (code deleted eff 01/01/2020) 95956 prolonged EEG monitoring (code deleted eff 01/01/2020)
Background
The Agency for Health Care Policy and Research has stated that information provided by video EEG monitoring has improved patient outcome by permitting accurate diagnoses and modified therapy. The American EEG Society has also noted that this procedure is widely regarded as safe and effective for evaluating seizures disorders. The American Epilepsy Society has stated that this technique is the method of choice for the evaluation of intractable and/or undiagnosed seizure disorders. Additionally, many studies have reported the usefulness of this technique, and recommended its use for the diagnosis of psychogenic seizures. An evidence report prepared for AHRQ (Ross, et al., 2001) concluded that Video EEG monitoring was useful for diagnosis of epilepsy if the EEG, CT, and MRI are non-diagnostic, and to aid in diagnosis in very young children, in patients with poorly characterized seizure types, and in those with suspected psychogenic seizures. The report concluded that video EEG has a role subsequent to a new diagnosis if the diagnosis is or becomes uncertain or if surgery is considered. The evidence suggests there is no role for standard EEG in routine monitoring of patients after a new diagnosis of epilepsy. Video EEG has a role subsequent to a new diagnosis if the diagnosis is or becomes uncertain or if surgery is considered. The role of video and ambulatory EEG is confined to refining or changing an uncertain diagnosis or in preoperative evaluations for seizure surgery. When seizures are frequent and features are atypical or uncertain, these EEGs may well contribute information necessary to correct a misdiagnosis. The literature describing these EEGs appears confined to specialists in academic centers
Reference
Cascino GD. Use of routine and video electroencephalography. Neurol Clin. 2001;19(2):271-287. Sheth RD. Intractable pediatric epilepsy: Presurgical evaluation. Semin Pediatr Neurol. 2000;7(3):158-165. Bowman ES, Coons PM. The differential diagnosis of epilepsy, pseudoseizures, dissociative identity disorder, and dissociative disorder not otherwise specified. Bull Menninger Clin. 2000;64(2):164-180. Cascino GD. Clinical indications and diagnostic yield of video-electroencephalographic monitoring in patients with seizures and spells. Mayo Clin Proc. 2002;77(10):1111-1120. Cascino GD. Video-EEG monitoring in adults. Epilepsia. 2002;43 Suppl 3:80-93. Cragar DE, Berry DT, Fakhoury TA, et al. A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures. Neuropsychol Rev. 2002;12(1):31-64. Ross SD, Estok R, Chopra S, et al. Management of newly diagnosed patients with epilepsy: A systematic review of the literature. Evidence Report/Technology Assessment No. 39 (Contract 290-97-0016 to MetaWorks, Inc.). AHRQ Publication No. 01-E038. Rockville, MD: Agency for Healthcare Research and Quality; September 2001. Hayes Technology Directory. Video Electroencephalogram (VEEG) for Diagnosis and Management of Epilepsy in Adults. Published October 31,2013. Hayes Technology Directory. Electroencephalogram (VEEG) for Diagnosis and Management of Epilepsy in Children. Published October 9, 2013
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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