Subject:
Noninvasive Electroencephalography (EEG)
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Noninvasive electroencephalography (EEG) records electrical activity of the brain via scalp electrodes. Electrical activity is recorded from standard sites on the scalp according to the International Federation of Clinical Neurophysiology (IFCN) 10 to 20 system of electrode placement.
According to Milliman Care Guidelines, an EEG can be used to confirm a diagnosis of epilepsy and classify it as partial (focal) or generalized. The EEG is also helpful in the evaluation and management of coma and impaired cognitive states. However, a normal EEG does not necessarily exclude the diagnosis of epilepsy, and an abnormal EEG may be unrelated to the patient's clinical presentation.
Related Policies
- Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder (Policy #077 in the Medicine Section)
Policy:
(NOTE: This policy does not address ambulatory EEG, video EEG, invasive EEG, and intraoperative EEG monitoring.
The following criteria are based on the Milliman Care Guidelines Ambulatory Care 23rd Edition for Noninvasive EEG.
For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
1. Noninvasive (scalp) EEG may be indicated for 1 or more of the following:
- Brain death determination
- Change in neurologic status (e.g., altered mental status, confusional state, delirium, encephalopathy, impaired cognition)
- Comatose patient after cardiac resuscitation
- Differentiation of epileptic from nonepileptic events
- Epilepsy, known, and need for repeat evaluation, as indicated by 1 or more of the following:
- Change in clinical status (eg, new symptoms)
- Focal epilepsy, and need to characterize location of seizure
- Withdrawal of anticonvulsant medication under consideration
- Epilepsy, suspected, and need for repeat evaluation after nondiagnostic initial EEG but persistent high clinical suspicion
- Epilepsy or nonfebrile infantile spasms (ie, West syndrome), suspected new onset
- Intracranial infection, suspected, as indicated by 1 or more of the following
- Bovine spongiform encephalopathy
- Creutzfeldt-Jakob disease
- Herpes simplex encephalitis
- Subacute sclerosing panencephalitis
- Persistent vegetative state or other disorder of consciousness
- Seizures associated with abnormal mental status or focal neurologic deficit
- Syncope with atypical features, as indicated by 1 or more of the following
- Automatisms (eg, chewing, lip smacking)
- Blue face during episode
- Clonic movements, one-sided
- Confusion after episode, prolonged
- Tongue biting during episode
- Tonic-clonic movements that were prolonged and began at same time as loss of consciousness
(NOTE: It is expected that the healthcare provider reading the EEG will have a reasonable degree of training in interpreting the study.)
2. Noninvasive EEG is not considered medically necessary for any one of the following indications:
a. Febrile seizures in children
b. Headache
[INFORMATIONAL NOTE: According to Milliman Care Guidelines, the published evidence on the use of EEG in children with febrile seizures demonstrates a lack of net benefit . An evidence-based review by Kimia AA, Bachur RG, Torres A, et al (Curr Opin Pediatr, 2015) stated that EEG is of limited value in the evaluation of febrile seizures; although abnormalities may be present on EEG, their clinical significance is unclear in terms of predicting febrile seizures recurrence or the development of epilepsy. Practice guidelines by the American Academy of Pediatrics and the Indian Academy of Pediatrics have concluded that EEG is not recommended for simple febrile seizures in children with normal neurologic examinations. A 2017 Cochrane systematic review found that there were no randomized controlled trials to support or refute the use of EEG and determine its optimal timing after complex febrile seizures in children.
For use of EEG in patients with headache, the evidence demonstrates a lack of net benefit. The American Academy of Neurology recommends against the use of EEG in the evaluation of headaches, citing the lower sensitivity of EEG in detecting structural lesions, as compared with CT scan or MRI, lack of demonstrable value in diagnosing migraine headaches, and the potential for discovery of incidental findings that would require performing unnecessary procedures and treatment. Furthermore, an evidence-based specialty society consensus guideline by the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre L'Epilepsie (LFCE) states that EEG is not considered to be useful in the investigation of headache.]
3. Noninvasive EEG is considered investigational for all other indications, including but not limited to the following:
- Alzheimer disease
- Attention-deficit hyperactivity disorder (ADHD) (also refer to a separate policy on 'Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder' - Policy #077 in the Medicine Section)
- Autism Spectrum Disorders
- Depression
- Posttraumatic Stress Disorder
- Preterm infant neurodevelopment prognostic evaluation
[INFORMATIONAL NOTE: According to Milliman Care Guidelines, the evidence on the use of EEG for these conditions/indications is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit vs. harm; additional research is recommended.]
Medicare Coverage:
There is no National Coverage Determination (NCD) specific to Noninvasive Electroencephalography (EEG). In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
For Electroencephalographic monitoring during surgical procedures, refer to National Coverage Determination (NCD) for Electroencephalographic Monitoring During Surgical Procedures Involving the Cerebral Vasculature (160.8). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
For ambulatory EEG, see National Coverage Determination (NCD) for Ambulatory EEG Monitoring (160.22). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Noninvasive Electroencephalography (EEG)
Electroencephalography (EEG)
EEG (Electroencephalography)
References:
1. Milliman Care Guidelines: Ambulatory Care 22nd Edition. EEG, Noninvasive. Copyright © 2018 MCG Health, LLC. Last Update: 5/14/2018.
2. Moeller J, Haider HA, Hirsch LJ. Electroencephalography (EEG) in the diagnosis of seizures and epilepsy. In: UpToDate, Garcia P, Dashe JF (Ed), UpToDate, Wlatham, MA. (Accessed on January 2, 2019.)
3. Sinha SR, Sullivan L, Sabau D, et al. American Clinical Neurophysiology Society Guideline 1: Minimum Technical Requirements for Performing Clinical Electroencephalography. J Clin Neurophysiol. 2016 Aug;33(4):303-307.
4. Acharya JN, Hani A, Cheek J, et al. American Clinical Neurophysiology Society Guideline 2: Guidelines for Standard Electrode Position Nomenclature. J Clin Neurophysiol. 2016 Aug;33(4):308-311.
5. Kuratani J, Pearl PL, Sullivan L, et al. American Clinical Neurophysiology Society Guideline 5: Minimum Technical Standards for Pediatric Electroencephalography. J Clin Neurophysiol. 2016 Aug;33(4):320-323.
6. Andre-Obadia N, Lamblin MD, Sauleau P. French recommendations on electroencephalography. Neurophysiologie Clinique/Clinical Neurophysiology. 2015;45:1-17.
7. Smith SJM. EEG in neurological conditions other than epilepsy: When does it help, what does it add? J Neurol Neurosurg Psychiatry. 2005;76(Suppl II):ii8-ii12.
8. Milliman Care Guidelines: Ambulatory Care 23rd Edition. EEG, Noninvasive. Copyright © 2019 MCG Health, LLC. Last Update: 2/11/2019.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
95812
95813
95816
95819
95822
95824
95957
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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