Electroencephalogram

Policy ID: M-34-029

Section: Diagnostic Medical

Effective Date: January 01, 2020

Revised Date: May 12, 2022

Revision Effective Date: July 01, 2022

Last Reviewed: May 24, 2022

Applies To: Commercial and Medicaid Expansion

Description

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.

Criteria

EEG may be considered 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 EEG in the evaluation of headache is considered not medically necessary.

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

Procedure Codes

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.

Procedure Codes

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 no 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.

Procedure Codes

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, and examination do not resolve the diagnostic uncertainties.
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.

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

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 non-convulsive 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.

Procedure Codes

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.

Procedure Codes

95957

Diagnosis Codes

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

A84.9

A84.89

A85.0

A85.1

A85.2

A85.8

A87.0

A87.1

A87.2

A87.8

A87.9

A92.5

A92.9

A92.31

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

C72.9

C72.20

C72.21

C72.22

C72.30

C72.31

C72.32

C72.40

C72.41

C72.42

C72.50

C72.59

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

D36.9

D36.10

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

E75.4

E75.6

E75.00

E75.01

E75.02

E75.09

E75.10

E75.11

E75.19

E75.23

E75.25

E75.29

E87.2

E88.40

E88.41

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

F44.9

F44.89

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

G04.2

G04.00

G04.01

G04.02

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

G11.2

G11.3

G11.4

G11.8

G11.9

G11.10

G11.11

G11.19

G12.0

G12.1

G12.8

G12.9

G12.20

G12.21

G12.22

G12.23

G12.24

G12.25

G12.29

G13.0

G13.1

G13.2

G13.8

G20

G21.0

G21.2

G21.3

G21.4

G21.8

G21.9

G21.11

G21.19

G23.0

G23.1

G23.2

G23.8

G23.9

G24.1

G24.2

G24.3

G24.4

G24.5

G24.8

G24.9

G24.01

G24.02

G24.09

G25.0

G25.1

G25.2

G25.3

G25.4

G25.5

G25.9

G25.61

G25.69

G25.70

G25.71

G25.79

G25.81

G25.82

G25.83

G25.89

G26

G30.0

G30.1

G30.8

G30.9

G31.1

G31.2

G31.9

G31.01

G31.09

G31.81

G31.82

G31.83

G31.84

G31.85

G31.89

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

G37.8

G37.9

G40.42

G40.89

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

G40.501

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

G40.901

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

G47.8

G47.9

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

G47.50

G47.51

G47.52

G47.53

G47.54

G47.59

G47.411

G47.419

G47.421

G47.429

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

G90.2

G90.3

G90.4

G90.8

G90.9

G90.01

G90.09

G90.50

G90.59

G90.511

G90.512

G90.513

G90.521

G90.522

G90.523

G91.0

G91.1

G91.2

G91.3

G91.4

G91.8

G91.9

G92

G92.8

G92.9

G92.00

G92.01

G92.02

G92.03

G92.04

G92.05

G93.0

G93.1

G93.2

G93.5

G93.6

G93.7

G93.9

G93.40

G93.41

G93.49

G93.89

G94

G95.0

G95.9

G95.11

G95.19

G95.20

G95.29

G95.81

G95.89

G96.9

G96.01

G96.08

G96.12

G96.89

G96.191

G96.198

G96.810

G96.811

G96.819

G97.1

G97.31

G97.32

G97.82

G97.83

G97.84

G98.0

G98.8

G99.0

G99.2

G99.8

H53.9

H53.19

H53.123

H55.00

I25.10

I35.0

I35.9

I46.2

I47.2

I49.8

I60.2

I60.4

I60.6

I60.7

I60.8

I60.9

I60.00

I60.01

I60.02

I60.10

I60.11

I60.12

I60.30

I60.31

I60.32

I60.50

I60.51

I60.52

I61.0

I61.1

I61.2

I61.3

I61.4

I61.5

I61.6

I61.8

I61.9

I62.1

I62.9

I62.00

I62.01

I62.02

I62.03

I63.6

I63.9

I63.00

I63.02

I63.09

I63.10

I63.12

I63.19

I63.20

I63.22

I63.29

I63.30

I63.39

I63.40

I63.49

I63.50

I63.59

I63.81

I63.89

I63.011

I63.012

I63.013

I63.019

I63.031

I63.032

I63.033

I63.039

I63.111

I63.112

I63.113

I63.119

I63.131

I63.132

I63.133

I63.139

I63.211

I63.212

I63.213

I63.219

I63.231

I63.232

I63.233

I63.239

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

I63.411

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

I63.511

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

I65.1

I65.8

I65.9

I65.01

I65.02

I65.03

I65.09

I65.21

I65.22

I65.23

I65.29

I66.3

I66.8

I66.9

I66.01

I66.02

I66.03

I66.09

I66.11

I66.12

I66.13

I66.19

I66.21

I66.22

I66.23

I66.29

I67.0

I67.1

I67.2

I67.3

I67.4

I67.5

I67.6

I67.7

I67.9

I67.81

I67.82

I67.83

I67.89

I67.841

I67.848

I67.850

I67.858

I68.0

I68.2

I68.8

I69.00

I69.10

I69.20

I69.30

I69.80

I69.90

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

I69.110

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

I69.210

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

I69.310

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

I69.810

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

I69.910

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

I71.1

I71.2

I71.6

I71.8

I71.9

I71.00

I71.01

I71.02

I71.03

I72.0

I77.71

I77.74

K70.41

K71.11

K72.01

K72.11

K72.90

K72.91

M34.83

M35.07

M40.295

M41.9

M41.25

M41.26

M41.44

M41.117

M41.125

M41.126

M41.129

M43.8X2

M43.02

M43.07

M43.12

M43.16

M43.17

M43.26

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

M48.07

M48.061

M48.062

M50.00

M50.01

M50.20

M50.21

M50.30

M50.021

M50.022

M50.023

M50.121

M50.122

M50.123

M50.222

M50.223

M50.321

M50.322

M51.9

M51.06

M51.16

M51.17

M51.26

M51.27

M51.36

M51.37

M51.86

M53.2X8

M53.85

M54.2

M54.5

M54.12

M54.14

M54.16

M54.17

M54.32

M54.41

M71.38

M80.88XA

M85.852

M96.0

M96.1

M99.63

M99.71

M99.73

N52.9

N75.0

N83.291

P28.2

P28.4

P36.9

P84

P90

P91.0

P91.1

P91.3

P91.4

P91.5

P91.9

P91.60

P91.61

P91.62

P91.63

P91.88

P91.811

P91.819

P96.89

Q04.3

Q04.8

Q06.8

Q07.8

Q07.00

Q27.30

Q27.39

Q28.2

Q28.3

Q85.1

Q85.01

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

R29.90

R29.818

R40.0

R40.1

R40.3

R40.4

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

R41.0

R41.3

R41.4

R41.9

R41.82

R41.89

R42

R43.2

R44.0

R44.1

R44.2

R44.3

R45.1

R45.4

R47.1

R47.01

R47.02

R47.81

R47.89

R55

R56.1

R56.9

R56.00

R56.01

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

S06.2X0A

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

S06.4X0A

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

S06.9X9A

S06.9X9D

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

S06.310A

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

S06.890S

S06.891S

S06.892S

S06.893S

S06.894S

S06.895S

S06.896S

S12.9XXA

S12.600A

S14.3XXA

S14.3XXD

S14.109A

S22.068A

S32.89XA

S32.009K

S32.019A

S32.020A

S33.5XXA

T42.6X1A

T68.XXXA

Covered Diagnosis Code for Procedure code 95824

G93.82

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.

ND Committee Review

Internal Medical Policy Committee 1-22-2020 adding codes

Internal Medical Policy Committee 1-19-2021 Coding update-added Diagnosis Codes: F10.130, F10.131, F10.132, F10.139, F10.930, F10.931, F10.932, F10.939, F11.13, F12.13, F13.130, F13.131, F13.132, F13.139, F14.13, F14.93, F15.13, F19.130, F19.131, F19.132, F19.139

Internal Medical Policy Committee 9-21-2021:

Added criteria from M-80 Electroencephalogram for Headaches; and
Removed Diagnosis code R40; and
Added Diagnosis codes for procedure codes 95812, 95813, 95816 and 95819
- G44.001, G44.009, G44.011, G44.019, G44.021, G44.029, G44.031, G44.039, G44.041, G44.049, G44.051, G44.059, G44.091, G44.099, G44.1, G44.201, G44.211, G44.219, G44.221, G44.229, G44.301, G44.309, G44.311, G44.319, G44.321, G44.329, G44.40; G44.41, G44.51, G44.52, G44.53, G44.59, G44.81, G44.82, G44.83, G44.84, G44.85, G44.86, G44.89, R51.0, R51.9; and
Updated language

Internal Medical Policy Committee 5-24-2022 Revision with coding updates

Removed the following Procedure codes 95700; 95712; 95713; 95715 and 95716
Added the following Procedure codes 95708; 95717; 95719; 95721; 95723; 95725; 95812; 95813; 95816; 95819 and 95822
Removed the following Diagnosis codes F10.11; F11.11; F11.23; F13.11; F11.93; F13.11; F14.11; F14.23; F15.11; F16.11; F18.11; F19.11; G40.11; P10.0; R40.2130; R40.2131; R40.2132; R40.2133; R40.2134; R40.2140; R40.2141; R40.2142; R40.2143; R40.2144; R40.2230; R40.2231; R40.2232; R40.2233; R40.2234; R40.2240; R40.2241; R40.2242; R40.2243; R40.2244; R40.2250; R40.2251; R40.252; R40.2253; R40.2254; R40.2330; R40.2331; R40.2332; R40.2333; R40.2334; R40.2360; R40.2363; R40.2410; R40.2411; R40.2412; R40.2413; R40.2414; R40.2420; R40.2421; R40.2422; R40.2423; R40.2430; R40.2431; R40.2432; R40.2433; R40.4234; R40.2440; R40.2441; R40.2442; R40.2443; R40.2444; R40.3; R56.1 and R56.9
Added too many diagnosis codes to individually list here (see policy).

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-34-028

Section: Diagnostic Medical

Effective Date: January 01, 2020

Revised Date: September 27, 2021

Revision Effective Date: October 01, 2021

Last Reviewed: September 21, 2021

Archived Date: June 30, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Transmission of the EEG by telephone, radio, or cable may be considered medically necessary when the closest medical facilities are located in remote areas which lack trained EEG interpreters for individuals with the following indications:

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.

Transmission of the EEG by internet or disc not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

95700

95705

95706

95707

95709

95710

95712

95713

95715

95716

The use of transmission of the EEG to determine electrocerebral silence, i.e., brain death, is considered experimental/investigational because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

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
Routine surface EEG is not diagnostic of a seizure disorder; or
Seizure activity is observed clinically but not captured by routine EEG; or
Seizure activity captured on routine EEG does not yield sufficient qualitative or quantitative data to determine a treatment regimen; or
Antiepileptic drug (AED) withdrawal is needed; or
Non-neurological causes of symptoms (e.g., 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.

Procedure Codes

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, 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.

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.

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

99184

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 non-convulsive 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.

Procedure Codes

95955

95961

95962

S8040

Procedure Codes

95957

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

Procedure Codes

95812

95813

98516

95819

Diagnosis Codes

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, 95955, and 99184.

F10.11

F11.11

F11.23

F11.93

F13.11

F13.230

F13.231

F13.232

F13.239

F13.930

F13.931

F13.932

F13.939

F14.11

F14.23

F15.11

F15.23

F15.93

F16.11

F18.11

F19.11

F19.230

F19.231

F19.232

F19.239

F19.930

F19.931

F19.932

F19.939

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

G40.11

G40.419

G40.501

G40.509

G40.801

G40.802

G40.803

G40.04

G40.811

G40.812

G40.813

G40.814

G40.821

G40.822

G40.823

G40.824

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

G43.101

G43.109

G43.111

G43.119

G43.501

G43.509

G43.511

G43.519

G43.601

G43.609

G43.611

G43.619

P10.0

P90

R40.1

R40.2110

R40.2111

R40.2112

R40.2113

R40.2114

R40.2120

R40.2121

R40.2122

R40.2123

R40.2124

R40.2130

R40.2131

R40.2132

R40.2133

R40.2134

R40.2140

R40.2141

R40.2142

R40.2143

R40.2144

R40.2210

R40.2211

R40.2212

R40.2213

R40.2214

R40.2220

R40.2221

R40.2222

R40.2223

R40.2224

R40.2230

R40.2231

R40.2232

R40.2233

R40.2234

R40.2240

R40.2241

R40.2242

R40.2243

R40.2244

R40.2250

R40.2251

R40.252

R40.2253

R40.2254

R40.2310

R40.2311

R40.2312

R40.2313

R40.2314

R40.2320

R40.2321

R40.2322

R40.2323

R40.2324

R40.2330

R40.2331

R40.2332

R40.2333

R40.2334

R40.2340

R40.2341

R40.2342

R40.2343

R40.2344

R40.2350

R40.2351

R40.2352

R40.2353

R40.2354

R40.2360

R40.2361

R40.2362

R40.2363

R40.2364

R40.2410

R40.2411

R40.2412

R40.2413

R40.2414

R40.2420

R40.2421

R40.2422

R40.2423

R40.2424

R40.2430

R40.2431

R40.2432

R40.2433

R40.2434

R40.2440

R40.2441

R40.2442

R40.2443

R40.2444

R40.3

R56.00

R56.01

R56.1

R56.9

R94.01

S06.5X0A

S065X0D

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

Non-covered Diagnosis codes

F90.0

F90.1

F90.2

F90.8

F90.9

Non-covered diagnosis codes for procedure codes: 95812, 95813, 95816, and 95819

G44.001

G44.009

G44.011

G44.019

G44.021

G44.029

G44.031

G44.039

G44.041

G44.049

G44.051

G44.059

G44.091

G44.099

G44.1

G44.201

G44.209

G44.211

G44.219

G44.221

G44.229

G44.301

G44.309

G44.311

G44.319

G44.321

G44.329

G44.40

G44.41

G44.51

G44.52

G44.53

G44.59

G44.81

G44.82

G44.83

G44.84

G44.85

G44.86

G44.89

R51.0

R51.9

Professional Statements and Societal Positions Guidelines

American Academy of Neurology 2019

ND Committee Review

Internal Medical Policy Committee 1-22-2020 adding codes

Internal Medical Policy Committee 9-21-2021:

Added criteria from M-80 Electroencephalogram for Headaches; and
Removed Diagnosis code R40; and
Added Diagnosis codes for procedure codes 95812, 95813, 95816 and 95819
- G44.001, G44.009, G44.011, G44.019, G44.021, G44.029, G44.031, G44.039, G44.041, G44.049, G44.051, G44.059, G44.091, G44.099, G44.1, G44.201, G44.211, G44.219, G44.221, G44.229, G44.301, G44.309, G44.311, G44.319, G44.321, G44.329, G44.40; G44.41, G44.51, G44.52, G44.53, G44.59, G44.81, G44.82, G44.83, G44.84, G44.85, G44.86, G44.89, R51.0, R51.9; and
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