Medical & Reimbursement Policies
Medical Policy
Policy Id
Topic
Section
Effective Date
Issued Date
Last Revision Date
Annual Review
Prepared By
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options services for Electroencephalogram (EEG) Technologies.
Definitions
Highmark Health Options (HHO) – Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services Delaware Medicaid: Diamond State Health Plan (DSHP), Delaware Healthy Children Program (DHCP), and Diamond State Health Plan Plus (DSHP) LTSS members.
Policy Position
Prior Authorization
Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup
Procedures
EEG may be considered medically necessary for the following indications (NOT an all inclusive list):
· Altered consciousness, such as stuporous, semi-comatose, or comatose states; or
· Atypical seizure variants in individuals experiencing bizarre, distressing symptoms as seen with "spike and wave stupor" or other forms of seizure disorders; or
· Head injury, where a subdural hematoma may be identified; or
· Differentiation of complicated migraine with epilepsy-like symptoms (e.g., auras, alterations in level of consciousness) from true seizure disorders.
The use of transmission of the EEG to determine electrocerebral silence, (i.e., brain death), is considered medically necessary.
The use of transmission of the EEG to determine electrocerebral silence not meeting the criteria as indicated in this policy is considered not medically necessary.
Video EEG (VEEG) monitoring may be considered medically necessary for ANY ONE of the following indications and/or conditions:
- The diagnosis cannot be made by neurological examination, standard EEG studies or ambulatory EEG monitoring; or
- Diagnosis of a seizure disorder (epilepsy) - individuals who have episodes suggestive of epilepsy when history, and examination do not resolve the diagnostic uncertainties; or
- Antiepileptic drug (AED) withdrawal is needed; or
- Non-neurological causes of symptoms (i.e., syncope and cardiac arrhythmias) have been ruled out; or
- To differentiate epileptic events from nonepileptic seizures such as psychogenic seizures; or
- Individual with intractable epilepsy is being evaluated for surgical intervention; or
- Seizure monitoring of a neonate or child is needed to develop or modify treatment; or
- To monitor neonates with hypoxic-ischemic encephalopathy (HIE) who are being treated with therapeutic hypothermia (TH)
VEEG monitoring not meeting the criteria as indicated in this policy is considered not medically necessary.
Note: Monitoring may be performed on an outpatient or inpatient basis, depending on the frequency and duration of seizure activity and length of time necessary to collect data. Individuals with frequent (at least three per week) intractable minor seizures and those individuals being evaluated for efficacy of drug treatment can be evaluated on an outpatient basis, in three (3) to 12 hours. Inpatient monitoring is required for individuals such as those with seizures that only occur at night, are infrequent, are clinically severe (such as prolonged complex partial seizures) or are provoked by drug withdrawal.
Ambulatory EEGs may be medically necessary in the following circumstances:
· When used in conjunction with ambulatory electrocardiogram (ECG) recordings for seizures suspected to be of cardiogenic origin; or
· When used in conjunction with electro-oculogram (EOG) and electromyogram (EMG) recordings for suspected seizures of sleep disturbances; or
· When used for quantification of seizures in individuals who experience frequent absence seizures; or
· Diagnosis of a seizure disorder (epilepsy) – individuals who have episodes suggestive of epilepsy when history, examination, and routine EEG do not resolve the diagnostic uncertainties, (inconclusive routine EEG); or
· When used in documenting seizures which are precipitated by naturally occurring cyclic events or environmental stimuli which are not reproducible in the hospital or clinic setting; or
· To monitor neonates with HIE who are being treated with TH.
Ambulatory EEGs not meeting the criteria as indicated in this policy is considered not medically necessary.
Ambulatory EEGs are considered experimental/investigational because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature in the following circumstances:
· For the study of neonates or unattended, uncooperative individuals; or
· In localization of seizure focus/foci when the seizure symptoms and/or other EEG recordings indicate the presence of bilateral foci or rapid generalization; or
· For final evaluation of individuals who are being considered as candidates for resective surgery.
Quantitative electroencephalogram (QEEG) may be considered medically necessary when used as an adjunct to traditional EEG and/or diagnostic evaluation of epilepsy when ANY ONE of the following criteria is met:
· The surface or long-term EEG is inconclusive and additional testing for possible epileptic spikes or seizures is needed; or
· Ambulatory recording is needed to facilitate subsequent visual EEG interpretation; or
· There is need for topographic voltage and dipole analysis in pre-surgical candidates with intractable epilepsy:
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- As continuous monitoring in the operating room for the early detection of an acute intracranial complication during cerebrovascular surgery (i.e., intracranial, carotid endarterectomy); or
- As monitoring for the detection of nonconvulsive seizures in high risk individuals in the intensive care unit and operating room.
QEEG not meeting the criteria as indicated in this policy is considered not medically necessary.
QEEG-based assessment is considered experimental/investigational when used as a diagnostic aid for attention deficit disorder because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Digital analysis of electroencephalogram (DEEG) is considered not medically necessary as there is no evidence that such additional processing and interpretation has been shown to improve outcomes in individual management.
Noncovered Services
The EEG is not useful in the routine evaluation of patients with headache (guideline). This does not exclude the use of EEG to evaluate headache patients with associated symptoms suggesting a seizure disorder, such as atypical migrainous aura or episodic loss of consciousness. Assuming head imaging capabilities are readily available, EEG is not recommended to exclude a structural cause for headache.
The use of EEG testing is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a comorbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Digital analysis of electroencephalogram (DEEG) is considered not medically necessary as there is no evidence that such additional processing and interpretation has been shown to improve outcomes in individual management.
References
InterQual® Level of Care Criteria. Acute Care Adult. 2021.
Baumgartner C, Pirker S. Video-EEG. Handb Clin Neurol. 2019;160:171-183.
. Anwar H, Khan QU, Nadeem N, Pervaiz I, et al. Epileptic seizures. Discoveries (Craiova). 2020;8(2):e110.
Hayes, Inc. Hayes Evolving Evidence Review. Home Video Electroencephalogram (VEEG) for Diagnosis and Management of Epilepsy and Seizures in Adults. Lansdale, PA: Hayes, Inc.; 05/05/2021.
Hayes, Inc. Hayes Evidence Analysis Research Brief. Use of Quantitative Electroencephalography to Predict treatment Response to Psychotropic Medication Use in Patients with Mood Disorders. Lansdale, PA: Hayes, Inc.; 02/23/2021.
van Dijk H, deBeus R, Kerson C, et al. Different spectral analysis methods for the theta/beta ratio calculate different ratios but do not distinguish ADHD from controls. Appl Psychophysiol Biofeedback. 2020;45(3):165-173.
Benedetti GM, Vartanian RJ, McCaffery H, Shellhaas RA. Early electroencephalogram background could guide tailored duration of monitoring for neonatal encephalopathy treated with therapeutic hypothermia. J Pediatr. 2020;221:81-87.e1.
Hasan TF, Tatum WO. When should we obtain a routine EEG while managing people with epilepsy? Epilepsy Behav Rep. 2021;16:100454.
Hernández-Ronquillo L, Thorpe L, Dash D, et al. Diagnostic accuracy of the ambulatory EEG vs. routine EEG for first single unprovoked seizures and seizure recurrence: The DX-Seizure Study. Front Neurol. 2020;11:223.
Rossetti AO, Schindler K, Sutter R, et al. Continuous vs routine electroencephalogram in critically ill adults with altered consciousness and no recent seizure: A multicenter randomized clinical trial. JAMA Neurol. 2020;77(10):1225-1232.
Hayes, Inc. Hayes Clinical Research Response. Ceribell (Ceribell Inc.) Rapid Response Electroencephalogram (EEG) for the Detection of Seizure Activity in Adults. Lansdale, PA: Hayes, Inc.; 11/24/2021.
Adamou M, Fullen T, Jones SL. EEG for Diagnosis of adult ADHD: A systematic review with narrative analysis. Front Psychiatry. 2020; 11:871.
van Dijk H, deBeus R, Kerson C, et al. Different spectral analysis methods for the theta/beta ratio calculate different ratios but do not distinguish ADHD from controls. Appl Psychophysiol Biofeedback. 2020; 45(3): 165-173.
Wolraich ML, Hagan JF, Allan C, et al. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019; 144(4).
