M-34-032

HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

M-34-032

Topic:

Electroencephalogram

Section:

Diagnostic Medical

Effective Date:

October 1, 2023

Issued Date:

October 1, 2023

Last Revision Date:

September 2023

Annual Review:

May 2022

An Electroencephalogram (EEG) is a recording of the electrical current potentials spontaneously from nerve cells in the brain onto the skull. Variations in wave characteristics correlate with neurological conditions and are used to diagnose conditions.

Policy Position

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.

Use of an EEG in the evaluation of a headache is considered not medically necessary.

EEG not meeting the criteria as indicated in this policy is considered not medically necessary.

95705	95706	95707	95708	95709	95710	95717
95719	95721	95723	95725	95812	95813	95816
95819	95822

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.

95824

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.

95700	95711	95712	95713	95714	95715	95716
95718	95720	95722	95724	95726	99184

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, do not resolve the diagnostic uncertainties; 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.

95700	95705	95706	95707	95708	95709	95710
95711	95712	95713	95714	95715	95716	95717
95718	95719	95720	95721	95722	95723	95724
95725	95726	99184

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:
- 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.

95955

95961

95962

S8040

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.

95957

Professional Statements and Societal Positions Guidelines

American Academy of Neurology 2019

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.

Covered Diagnosis Codes for Procedure Codes 95700, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726, 95812, 95813, 95816, 95819, 95822, and 99184

A02.21	A17.0	A17.82	A39.0	A39.2	A39.3	A39.4
A39.81	A41.9	A42.82	A50.41	A50.42	A52.13	A52.14
A52.15	A54.81	A81.00	A81.01	A81.09	A83.0	A83.1
A83.2	A83.3	A83.4	A83.8	A83.9	A84.0	A84.1
A84.89	A84.9	A85.0	A85.1	A85.2	A85.8	A87.0
A87.1	A87.2	A87.8	A87.9	A92.31	A92.5	A92.9
B00.3	B00.4	B01.11	B02.0	B02.1	B05.0	B06.01
B10.01	B10.09	B10.81	B26.1	B26.2	B37.5	B38.4
B39.4	B39.5	B39.9	B45.1	B83.2	B94.1	C31.9
C41.2	C41.9	C50.911	C69.22	C70.0	C70.1	C70.9
C71.0	C71.1	C71.2	C71.3	C71.4	C71.5	C71.6
C71.7	C71.8	C71.9	C72.0	C72.1	C72.20	C72.21
C72.22	C72.30	C72.31	C72.32	C72.40	C72.41	C72.42
C72.50	C72.59	C72.9	C73	C79.31	C79.49	C79.51
D18.02	D32.0	D32.1	D32.9	D33.0	D33.1	D33.2
D33.3	D33.4	D33.7	D35.5	D36.10	D36.9	D42.0
D42.1	D42.9	D43.0	D43.1	D43.2	D43.4	D44.6
D49.6	D49.7	E03.5	E03.9	E05.00	E75.00	E75.01
E75.02	E75.09	E75.10	E75.11	E75.19	E75.23	E75.25
E75.29	E75.4	E75.6	E88.40	E88.41	E88.43	F02.80
F02.81	F03.90	F03.91	F04	F05	F06.1	F06.8
F10.239	F10.930	F10.931	F10.932	F10.939	F13.230	F13.231
F13.232	F13.239	F13.930	F13.931	F13.932	F13.939	F15.13
F15.23	F15.93	F19.130	F19.131	F19.132	F19.139	F19.230
F19.231	F19.232	F19.239	F19.930	F19.931	F19.932	F19.939
F28	F29	F41.0	F44.4	F44.5	F44.6	F44.7
F44.89	F44.9	F45.8	F68.8	F84.0	F84.2	F84.3
F84.5	F84.8	F84.9	F95.0	F95.1	F95.2	F95.8
F95.9	F98.0	F98.1	G00.0	G00.1	G00.2	G00.3
G00.8	G00.9	G01	G02	G03.0	G03.1	G03.2
G03.8	G03.9	G04.00	G04.01	G04.02	G04.2	G04.30
G04.31	G04.32	G04.39	G04.81	G04.82	G04.89	G04.90
G04.91	G05.3	G05.4	G06.0	G06.1	G06.2	G07
G08	G09	G10	G11.0	G11.10	G11.11	G11.19
G11.2	G11.3	G11.4	G11.8	G11.9	G12.0	G12.1
G12.20	G12.21	G12.22	G12.23	G12.24	G12.25	G12.29
G12.8	G12.9	G13.0	G13.1	G13.2	G13.8	G21.0
G21.11	G21.19	G21.2	G21.3	G21.4	G21.8	G21.9
G23.0	G23.1	G23.2	G23.3	G23.8	G23.9	G24.01
G24.02	G24.09	G24.1	G24.2	G24.3	G24.4	G24.5
G24.8	G24.9	G25.0	G25.1	G25.2	G25.3	G25.4
G25.5	G25.61	G25.69	G25.70	G25.71	G25.79	G25.81
G25.82	G25.83	G25.89	G25.9	G26	G30.0	G30.1
G30.8	G30.9	G31.01	G31.09	G31.1	G31.2	G31.81
G31.82	G31.83	G31.84	G31.85	G31.89	G31.9	G32.0
G32.81	G32.89	G35	G36.0	G36.1	G36.8	G36.9
G37.0	G37.1	G37.2	G37.3	G37.4	G37.5	G37.81
G37.89	G37.9	G40.001	G40.009	G40.011	G40.019	G40.101
G40.109	G40.111	G40.119	G40.201	G40.209	G40.211	G40.219
G40.301	G40.309	G40.311	G40.319	G40.401	G40.409	G40.411
G40.419	G40.42	G40.501	G40.509	G40.801	G40.802	G40.803
G40.804	G40.811	G40.812	G40.813	G40.814	G40.821	G40.822
G40.823	G40.824	G40.833	G40.834	G40.89	G40.901	G40.909
G40.911	G40.919	G40.A01	G40.A09	G40.A11	G40.A19	G40.B01
G40.B09	G40.B11	G40.B19	G43.001	G43.009	G43.019	G43.101
G43.109	G43.111	G43.119	G43.401	G43.409	G43.411	G43.419
G43.501	G43.509	G43.511	G43.519	G43.601	G43.609	G43.611
G43.619	G43.701	G43.709	G43.711	G43.719	G43.801	G43.809
G43.811	G43.819	G43.901	G43.909	G43.B0	G43.B1	G45.1
G45.4	G45.8	G45.9	G47.00	G47.01	G47.09	G47.10
G47.11	G47.12	G47.13	G47.14	G47.19	G47.20	G47.21
G47.22	G47.23	G47.24	G47.25	G47.26	G47.27	G47.29
G47.30	G47.31	G47.32	G47.33	G47.34	G47.35	G47.36
G47.37	G47.39	G47.411	G47.419	G47.421	G47.429	G47.50
G47.51	G47.52	G47.53	G47.54	G47.59	G47.8	G47.9
G50.0	G51.4	G52.9	G63	G65.0	G65.1	G65.2
G80.0	G80.1	G80.2	G80.3	G80.4	G80.8	G80.9
G90.01	G90.09	G90.2	G90.3	G90.4	G90.50	G90.511
G90.512	G90.513	G90.521	G90.522	G90.523	G90.59	G90.8
G90.9	G91.0	G91.1	G91.2	G91.3	G91.4	G91.8
G91.9	G92	G92.00	G92.01	G92.02	G92.03	G92.04
G92.05	G92.8	G92.9	G93.0	G93.1	G93.2	G93.40
G93.41	G93.42	G93.43	G93.44	G93.49	G93.5	G93.6
G93.7	G93.89	G93.9	G94	G95.0	G95.11	G95.19
G95.20	G95.29	G95.81	G95.89	G95.9	G96.01	G96.08
G96.12	G96.191	G96.198	G96.810	G96.811	G96.819	G96.89
G96.9	G97.1	G97.31	G97.32	G97.82	G97.83	G97.84
G98.0	G98.8	G99.0	G99.2	G99.8	H53.123	H53.19
H53.9	H55.00	I25.10	I35.0	I35.9	I46.2	I47.20
I47.29	I49.8	I60.00	I60.01	I60.02	I60.10	I60.11
I60.12	I60.2	I60.30	I60.31	I60.32	I60.4	I60.50
I60.51	I60.52	I60.6	I60.7	I60.8	I60.9	I61.0
I61.1	I61.2	I61.3	I61.4	I61.5	I61.6	I61.8
I61.9	I62.00	I62.01	I62.02	I62.03	I62.1	I62.9
I63.00	I63.011	I63.012	I63.013	I63.019	I63.02	I63.031
I63.032	I63.033	I63.039	I63.09	I63.10	I63.111	I63.112
I63.113	I63.119	I63.12	I63.131	I63.132	I63.133	I63.139
I63.19	I63.20	I63.211	I63.212	I63.213	I63.219	I63.22
I63.231	I63.232	I63.233	I63.239	I63.29	I63.30	I63.311
I63.312	I63.313	I63.319	I63.321	I63.322	I63.323	I63.329
I63.331	I63.332	I63.333	I63.339	I63.341	I63.342	I63.343
I63.349	I63.39	I63.40	I63.411	I63.412	I63.413	I63.419
I63.421	I63.422	I63.423	I63.429	I63.431	I63.432	I63.433
I63.439	I63.441	I63.442	I63.443	I63.449	I63.49	I63.50
I63.511	I63.512	I63.513	I63.519	I63.521	I63.522	I63.523
I63.529	I63.531	I63.532	I63.533	I63.539	I63.541	I63.542
I63.543	I63.549	I63.59	I63.6	I63.81	I63.89	I63.9
I65.01	I65.02	I65.03	I65.09	I65.1	I65.21	I65.22
I65.23	I65.29	I65.8	I65.9	I66.01	I66.02	I66.03
I66.09	I66.11	I66.12	I66.13	I66.19	I66.21	I66.22
I66.23	I66.29	I66.3	I66.8	I66.9	I67.0	I67.1
I67.2	I67.3	I67.4	I67.5	I67.6	I67.7	I67.81
I67.82	I67.83	I67.841	I67.848	I67.850	I67.858	I67.89
I67.9	I68.0	I68.2	I68.8	I69.00	I69.010	I69.011
I69.012	I69.013	I69.014	I69.015	I69.018	I69.019	I69.020
I69.021	I69.022	I69.023	I69.028	I69.031	I69.032	I69.033
I69.034	I69.039	I69.041	I69.042	I69.043	I69.044	I69.049
I69.051	I69.052	I69.053	I69.054	I69.059	I69.061	I69.062
I69.063	I69.064	I69.065	I69.069	I69.090	I69.091	I69.092
I69.093	I69.098	I69.10	I69.110	I69.111	I69.112	I69.113
I69.114	I69.115	I69.118	I69.119	I69.120	I69.121	I69.122
I69.123	I69.128	I69.131	I69.132	I69.133	I69.134	I69.139
I69.141	I69.142	I69.143	I69.144	I69.149	I69.151	I69.152
I69.153	I69.154	I69.159	I69.161	I69.162	I69.163	I69.164
I69.165	I69.169	I69.190	I69.191	I69.192	I69.193	I69.198
I69.20	I69.210	I69.211	I69.212	I69.213	I69.214	I69.215
I69.218	I69.219	I69.220	I69.221	I69.222	I69.223	I69.228
I69.231	I69.232	I69.233	I69.234	I69.239	I69.241	I69.242
I69.243	I69.244	I69.249	I69.251	I69.252	I69.253	I69.254
I69.259	I69.261	I69.262	I69.263	I69.264	I69.265	I69.269
I69.290	I69.291	I69.292	I69.293	I69.298	I69.30	I69.310
I69.311	I69.312	I69.313	I69.314	I69.315	I69.318	I69.319
I69.320	I69.321	I69.322	I69.323	I69.328	I69.331	I69.332
I69.333	I69.334	I69.339	I69.341	I69.342	I69.343	I69.344
I69.349	I69.351	I69.352	I69.353	I69.354	I69.359	I69.361
I69.362	I69.363	I69.364	I69.365	I69.369	I69.390	I69.391
I69.392	I69.393	I69.398	I69.80	I69.810	I69.811	I69.812
I69.813	I69.814	I69.815	I69.819	I69.820	I69.821	I69.822
I69.823	I69.828	I69.831	I69.832	I69.833	I69.834	I69.839
I69.841	I69.842	I69.843	I69.844	I69.849	I69.851	I69.852
I69.853	I69.854	I69.859	I69.861	I69.862	I69.863	I69.864
I69.865	I69.869	I69.890	I69.891	I69.892	I69.893	I69.898
I69.90	I69.910	I69.911	I69.912	I69.913	I69.914	I69.915
I69.918	I69.919	I69.920	I69.921	I69.922	I69.923	I69.928
I69.931	I69.932	I69.933	I69.934	I69.939	I69.941	I69.942
I69.943	I69.944	I69.949	I69.951	I69.952	I69.953	I69.954
I69.959	I69.961	I69.962	I69.963	I69.964	I69.965	I69.969
I69.990	I69.991	I69.992	I69.993	I69.998	I70.8	I71.00
I71.01	I71.02	I71.03	I71.1	I71.2	I71.6	I71.8
I71.9	I72.0	I77.71	I77.74	K70.41	K71.11	K72.01
K72.11	K72.90	K72.91	M34.83	M35.07	M40.295	M41.117
M41.125	M41.126	M41.129	M41.25	M41.26	M41.44	M41.9
M43.02	M43.07	M43.12	M43.16	M43.17	M43.26	M43.8X2
M46.1	M47.12	M47.14	M47.16	M47.22	M47.26	M47.27
M47.812	M47.813	M47.816	M47.817	M47.892	M47.896	M48.02
M48.061	M48.062	M48.07	M50.00	M50.01	M50.021	M50.022
M50.023	M50.121	M50.122	M50.123	M50.20	M50.21	M50.222
M50.223	M50.30	M50.321	M50.322	M51.06	M51.16	M51.17
M51.26	M51.27	M51.36	M51.37	M51.86	M51.9	M53.2X8
M53.85	M54.12	M54.14	M54.16	M54.17	M54.2	M54.32
M54.41	M54.5	M71.38	M80.88XA	M85.852	M96.0	M96.1
M99.63	M99.71	M99.73	N52.9	N75.0	N83.291	P28.2
P28.40	P28.41	P28.42	P28.43	P28.49	P36.9	P84
P90	P91.0	P91.1	P91.3	P91.4	P91.5	P91.60
P91.61	P91.62	P91.63	P91.811	P91.819	P91.88	P91.9
P96.89	Q04.3	Q04.8	Q06.8	Q07.00	Q07.8	Q27.30
Q27.39	Q28.2	Q28.3	Q85.01	Q85.1	Q99.8	Q99.9
R00.0	R05.4	R06.81	R25.0	R25.1	R25.2	R25.3
R25.8	R25.9	R26.0	R26.1	R26.89	R29.5	R29.818
R29.90	R40.0	R40.1	R40.20	R40.2110	R40.2111	R40.2112
R40.2113	R40.2114	R40.2120	R40.2121	R40.2122	R40.2123	R40.2124
R40.2210	R40.2211	R40.2212	R40.2213	R40.2214	R40.2220	R40.2221
R40.2222	R40.2223	R40.2224	R40.2310	R40.2311	R40.2312	R40.2313
R40.2314	R40.2320	R40.2321	R40.2322	R40.2323	R40.2324	R40.2340
R40.2341	R40.2342	R40.2343	R40.2344	R40.2350	R40.2351	R40.2352
R40.2353	R40.2354	R40.2361	R40.2362	R40.2364	R40.3	R40.4
R41.0	R41.3	R41.4	R41.82	R41.89	R41.9	R42
R43.2	R44.0	R44.1	R44.2	R44.3	R45.1	R45.4
R47.01	R47.02	R47.1	R47.81	R47.89	R55	R56.00
R56.01	R56.1	R56.9	R94.01	S06.0X0A	S06.0X0D	S06.0X0S
S06.0X1A	S06.0X1D	S06.0X1S	S06.0X9A	S06.0X9D	S06.0X9S	S06.1X0A
S06.1X0D	S06.1X0S	S06.1X1A	S06.1X1D	S06.1X1S	S06.1X2A	S06.1X2D
S06.1X2S	S06.1X3A	S06.1X3D	S06.1X3S	S06.1X4A	S06.1X4D	S06.1X4S
S06.1X5A	S06.1X5D	S06.1X5S	S06.1X6A	S06.1X6D	S06.1X6S	S06.1X7A
S06.1X8A	S06.1X9A	S06.1X9D	S06.1X9S	S06.1XAA	S06.1XAD	S06.1XAS
S06.2X0A	S06.2X0D	S06.2X0S	S06.2X1A	S06.2X1D	S06.2X1S	S06.2X2A
S06.2X2D	S06.2X2S	S06.2X3A	S06.2X3D	S06.2X3S	S06.2X4A	S06.2X4D
S06.2X4S	S06.2X5A	S06.2X5D	S06.2X5S	S06.2X6A	S06.2X6D	S06.2X6S
S06.2X7A	S06.2X8A	S06.2X9A	S06.2X9D	S06.2X9S	S06.2XAA	S06.2XAD
S06.2XAS	S06.301A	S06.301D	S06.301S	S06.302A	S06.302D	S06.302S
S06.303A	S06.303D	S06.303S	S06.304A	S06.304D	S06.304S	S06.305A
S06.305D	S06.305S	S06.306A	S06.306D	S06.306S	S06.307A	S06.308A
S06.309A	S06.309D	S06.309S	S06.30AA	S06.30AD	S06.30AS	S06.310A
S06.310D	S06.310S	S06.311A	S06.311D	S06.311S	S06.312A	S06.312D
S06.312S	S06.313A	S06.313D	S06.313S	S06.314A	S06.314D	S06.315A
S06.315D	S06.315S	S06.316A	S06.316D	S06.316S	S06.317A	S06.318A
S06.319A	S06.319D	S06.319S	S06.320A	S06.320D	S06.320S	S06.321A
S06.321D	S06.321S	S06.322A	S06.322D	S06.322S	S06.323A	S06.323D
S06.323S	S06.324A	S06.324D	S06.324S	S06.325A	S06.325D	S06.325S
S06.326A	S06.326D	S06.326S	S06.327A	S06.328A	S06.329A	S06.329D
S06.329S	S06.330A	S06.330D	S06.330S	S06.331A	S06.331D	S06.331S
S06.332A	S06.332D	S06.332S	S06.333A	S06.333D	S06.333S	S06.334A
S06.334D	S06.334S	S06.335A	S06.335D	S06.335S	S06.336A	S06.336D
S06.336S	S06.337A	S06.338A	S06.339A	S06.339D	S06.339S	S06.340A
S06.340D	S06.340S	S06.341A	S06.341D	S06.341S	S06.342A	S06.342D
S06.342S	S06.343A	S06.343D	S06.343S	S06.344A	S06.344D	S06.344S
S06.345A	S06.345D	S06.345S	S06.346A	S06.346D	S06.346S	S06.347A
S06.348A	S06.349A	S06.349D	S06.349S	S06.350A	S06.350D	S06.350S
S06.351A	S06.351D	S06.351S	S06.352A	S06.352D	S06.352S	S06.353A
S06.353D	S06.353S	S06.354A	S06.354D	S06.354S	S06.355A	S06.355D
S06.355S	S06.356D	S06.356S	S06.357A	S06.358A	S06.359A	S06.359D
S06.359S	S06.360A	S06.360D	S06.360S	S06.361A	S06.361D	S06.361S
S06.362A	S06.362D	S06.362S	S06.363A	S06.363D	S06.363S	S06.364A
S06.364D	S06.364S	S06.365A	S06.365D	S06.365S	S06.366A	S06.366D
S06.366S	S06.367A	S06.368A	S06.369A	S06.369D	S06.369S	S06.370A
S06.370D	S06.370S	S06.371A	S06.371D	S06.371S	S06.372A	S06.372D
S06.372S	S06.373A	S06.373D	S06.373S	S06.374A	S06.374D	S06.374S
S06.375A	S06.375D	S06.375S	S06.376A	S06.376D	S06.376S	S06.377A
S06.378A	S06.379A	S06.379D	S06.379S	S06.380A	S06.380D	S06.380S
S06.381A	S06.381D	S06.381S	S06.382A	S06.382D	S06.382S	S06.383A
S06.383D	S06.383S	S06.384A	S06.384D	S06.384S	S06.385A	S06.385D
S06.385S	S06.386A	S06.386D	S06.386S	S06.387A	S06.388A	S06.389A
S06.389D	S06.389S	S06.4X0A	S06.4X0D	S06.4X0S	S06.4X1A	S06.4X1D
S06.4X1S	S06.4X2A	S06.4X2D	S06.4X2S	S06.4X3A	S06.4X3D	S06.4X3S
S06.4X4A	S06.4X4D	S06.4X4S	S06.4X5A	S06.4X5D	S06.4X5S	S06.4X6A
S06.4X6D	S06.4X6S	S06.4X7A	S06.4X8A	S06.4X9A	S06.4X9D	S06.4X9S
S06.5X0A	S06.5X0D	S06.5X0S	S06.5X1A	S06.5X1D	S06.5X1S	S06.5X2A
S06.5X2D	S06.5X2S	S06.5X3A	S06.5X3D	S06.5X3S	S06.5X4A	S06.5X4D
S06.5X4S	S06.5X5A	S06.5X5D	S06.5X5S	S06.5X6A	S06.5X6D	S06.5X6S
S06.5X7A	S06.5X8A	S06.5X9A	S06.5X9D	S06.5X9S	S06.6X0A	S06.6X0D
S06.6X0S	S06.6X1A	S06.6X1D	S06.6X1S	S06.6X2A	S06.6X2D	S06.6X2S
S06.6X3A	S06.6X3D	S06.6X3S	S06.6X4A	S06.6X4D	S06.6X4S	S06.6X5A
S06.6X5D	S06.6X5S	S06.6X6A	S06.6X6D	S06.6X6S	S06.6X7A	S06.6X8A
S06.6X9A	S06.6X9S	S06.890S	S06.891S	S06.892S	S06.893S	S06.894S
S06.895S	S06.896S	S06.89AA	S06.89AD	S06.89AS	S06.9X9A	S06.9X9D
S06.9XAA	S06.9XAD	S06.9XAS	S12.600A	S12.9XXA	S14.109A	S14.3XXA
S14.3XXD	S22.068A	S32.009K	S32.019A	S32.020A	S32.89XA	S33.5XXA
T42.6X1A	T68.XXXA

Covered Diagnosis Code for Procedure Code 95824

G93.82

Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

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 co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Links

Link to Provider Resource Center for the Medical Policy Update

10/2020, Revised Criteria for EEG Technologies

Link to References

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.