Electroencephalogram (EEG) Technologies

Policy ID: M-34-025

Section: Diagnostic Medical

Effective Date: January 01, 2020

Revised Date: December 28, 2020

Revision Effective Date: January 01, 2021

Last Reviewed: January 19, 2021

Description

An 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.

Radio and cable telemetry of the EEG may be considered medically necessary for:

EEG recording during provocation testing (e.g., withdrawal of anticonvulsant medications), which can be safely undertaken only in the immediate proximity of emergency medical personnel and technology; and
EEG recording attempting to localize the seizure focus’ prior to surgery when ambulation is desirable (e.g., when seizures are triggered by specific environmental stimuli or daily events).

Transmission of the EEG by telephone, radio, or cable is considered not medically necessary for any other indication not listed above.

Procedure Codes

95700	95706	95712	95707	95709	95710	95713
95715	95716

Video EEG 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 cassette 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)

Video EEG monitoring for any other indication not listed above 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.

Twenty-four hour ambulatory cassette-recorded 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 patients who experience frequent absence seizures; 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.

Twenty-four hour ambulatory cassette-recorded EEGs for any other indication not listed above is considered not medically necessary.

Procedure Codes

95700	95711	95714	95718	95720	95722	95724
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.

Quantitative electroencephalogram (QEEG) for any other indication not listed above is considered not medically necessary.

Procedure Codes

95955

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

Twenty-four hour ambulatory cassette-recorded EEGs are considered experimental/investigational and, therefore non-covered in the following circumstances:

For the study of neonates or unattended, uncooperative individuals; and
In localization of seizure focus/foci when the seizure symptoms and/or other EEG recordings indicate the presence of bilateral foci or rapid generalization; and
For final evaluation of individuals who are being considered as candidates for resective surgery.

Scientific evidence does not demonstrate the efficacy of twenty-four hour ambulatory cassette-recorded EEGs in certain instances.

Telephone transmission of the EEG to determine electrocerebral silence, i.e., brain death, is considered experimental/investigational, and therefore non-covered. Scientific evidence does not support its use in these instances.

Procedure Codes

95824

Quantitative electroencephalographic-based assessment (QEEG) is considered experimental/investigational and, therefore non-coveredwhen usedas a diagnostic aid for attention deficit/hyperactivity disorder. Scientific evidence does not support its use as a diagnostic aid for this condition.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 95700, 95706, 95707, 95709, 95710, 97511, 97512, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726, 95955, and 99184.

F10.11	F10.130	F10.131	F10.132	F10.139	F10.930	F10.931
F10.932	F10.939	F11.11	F11.13	F11.23	F11.93	F12.11
F12.13	F12.23	F12.93	F13.11	F13.130	F13.131	F13.132
F13.139	F13.230	F13.231	F13.232	F13.239	F13.930	F13.931
F13.932	F13.939	F14.11	F14.13	F14.23	F14.93	F15.11
F15.13	F15.23	F15.93	F16.11	F17.203	F17.213	F17.223
F17.293	F18.11	F19.11	F19.130	F19.131	F19.132	F19.139
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	G40.411	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
G40.89	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	R40.0
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	R40.2252	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	R40.4
R56.00	R56.01	R56.1	R56.9	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

Non-covered Diagnosis codes for Procedure Code

F90.0

F90.1

F90.2

F90.8

F90.9

Professional Statements and Societal Positions Guidelines

Not Applicable

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

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.

Section: Diagnostic Medical

Effective Date: January 01, 2020

Revised Date: January 01, 2020

Last Reviewed: January 22, 2020

Archived Date: December 31, 2020

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.

Radio and cable telemetry of the EEG may be considered medically necessary for:

EEG recording during provocation testing (e.g., withdrawal of anticonvulsant medications), which can be safely undertaken only in the immediate proximity of emergency medical personnel and technology; and
EEG recording attempting to localize the seizure focus’ prior to surgery when ambulation is desirable (e.g., when seizures are triggered by specific environmental stimuli or daily events).

Transmission of the EEG by telephone, radio, or cable is considered not medically necessary for any other indication not listed above.

Procedure Codes

95700	95706	95712	95707	95709	95710	95713
95715	95716

Video EEG 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 cassette 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)

Video EEG monitoring for any other indication not listed above is considered not medically necessary.

Twenty-four hour ambulatory cassette-recorded 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 patients who experience frequent absence seizures; 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.

Twenty-four hour ambulatory cassette-recorded EEGs for any other indication not listed above is considered not medically necessary.

Procedure Codes

95700	95711	95714	95718	95720	95722	95724
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 nonconvulsive seizures in high risk individuals in the intensive care unit and operating room.

Quantitative electroencephalogram (QEEG) for any other indication not listed above is considered not medically necessary.

Procedure Codes

95955

Procedure Codes

95957

Twenty-four hour ambulatory cassette-recorded EEGs are considered experimental/investigational and, therefore non-covered in the following circumstances:

For the study of neonates or unattended, uncooperative individuals; and
In localization of seizure focus/foci when the seizure symptoms and/or other EEG recordings indicate the presence of bilateral foci or rapid generalization; and
For final evaluation of individuals who are being considered as candidates for resective surgery.

Scientific evidence does not demonstrate the efficacy of twenty-four hour ambulatory cassette-recorded EEGs in certain instances.

Procedure Codes

95824

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 95700, 95706, 95707, 95709, 95710, 95712, 97511, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726, 95955 and 99184

F10.11	F11.11	F11.23	F11.93	F12.11	F12.23	F12.93
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	F17.203	F17.213	F17.223	F17.293	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	G40.411	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
G40.89	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	R40.0
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	R40.2252	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	R40.4
R56.00	R56.01	R56.1	R56.9	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

Non-covered Diagnosis codes for Procedure Code

F90.0

F90.1

F90.2

F90.8

F90.9

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