Electroencephalogram

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

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

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.

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, 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.

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

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

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

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-34-027

Section: Diagnostic Medical

Effective Date: January 01, 2020

Revised Date: August 18, 2021

Revision Effective Date: November 01, 2021

Last Reviewed: September 21, 2021

Archived Date: September 30, 2021

Applies To: Commercial Only

Description

Criteria

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

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

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

G44.89

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, G44.89, R51.0, R51.9; and
Updated language

Links

References (PDF)

Disclaimer

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