Clinical UM Guideline
Subject:
Guideline #:
Status:
Electroencephalography (EEG) Testing: Ambulatory and Video
CG-MED-18
Current Effective Date:
Reviewed
Last Review Date:
10/22/2008
08/28/2008
Description
This document addresses the use of electroencephalography (EEG) testing when used as an ambulatory test or
when a standard EEG is combined with the use of video monitoring. Standard EEG testing measures the electrical
activity of the brain, and is used primarily for the diagnosis and management of seizure disorders. For seizure
disorders that exhibit more variation, EEG testing may be enhanced by extending the testing time with ambulatory
monitoring or testing during sleep with video monitoring, so that response to specific triggers indicated by clinical
history may be observed.
Clinical Indications
Medically Necessary:
Ambulatory EEG testing is considered medically necessary when any of the following criteria are met:
1. To differentiate between seizures and paroxysmal non-epileptic events;
2. For patients when a clinical history suggestive of seizures and standard EEG testing is non-diagnostic;
3. For evaluation of seizures or syncope suspected to be cardiogenic in etiology when cardiac evaluation has
not been diagnostic;
4. When used for quantification of seizures in patients who experience frequent seizures, such as “absence”
(petit mal) or myoclonic seizures, among others;
5. When used in documenting seizures, which are, precipitated by naturally occurring, cyclic events or
extraneous stimuli which are not reproducible in the hospital or laboratory setting. (e.g., loud sounds,
flashing lights, sudden movements).
Standard EEG testing with Video Monitoring is considered medically necessary when any of the following criteria
are met:
1. For patients with a clinical history suggestive of seizures in whom standard EEG testing has been nondiagnostic;
2. To correctly classify seizure type where treatment is defined by seizure type in members with documented
seizures;
3. To localize the seizure focus in members with documented medically refractory seizures prior to possible
resective epilepsy surgery;
4. To distinguish between epileptic seizures and nonepileptic episodes, (psychogenic seizures or
pseudoseizures, syncope, hyperventilation episodes).
Not Medically Necessary:
The use of routine video enhancement of standard EEG testing is considered not medically necessary when criteria
outlined above have not been met.
The use of ambulatory EEG is considered not medically necessary in the following circumstances:
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Coverage Guidelines take precedence
over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that
services are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in
adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
Page 1 of 5
© CPT Only – American Medical Association
Clinical UM Guideline
CG-MED-18
Electroencephalography (EEG) Testing: Ambulatory and Video
1. When used for unattended, non cooperative patients;
2. When criteria outlined above have not been met.
Place of Service/Duration/Goal Length of Stay
Place(s) of Service:
Duration:
Goal Length of Stay:
Outpatient, for ambulatory EEG
23 hr observation to inpatient for video EEG
23 hr observation to 4 days inpatient for video EEG
The goal length of stay for video EEG would be 23hr observation. However, the event
being monitored may not occur in this time frame. Admission may be necessary for
further monitoring or for preoperative localization of seizure foci prior to resective
epilepsy surgery. The length of stay is assigned per day, based on clinical review, up to
4 days. Inpatient stay beyond 4 days requires physician review.
Case Management
Case management may be necessary for concurrent review when testing requires admission.
Discharge Plan
If the testing requires admission, discharge planning would include education of the patient, family, and/or
caregiver as follows:
ƒ The physician plan of care and follow-up;
ƒ Prevention of seizures;
ƒ Triggers that may be responsible for seizures;
ƒ How to identify aura or impending onset of a seizure;
ƒ How to recognize seizure emergencies.
Coding
The following codes for treatments and procedures applicable to this document are included below for informational purposes.
Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider
reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or
non-coverage of these services as it applies to an individual member.
CPT
95951
95953
Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel
telemetry, combined electroencephalographic (EEG) and video recording and
interpretation, (eg, for presurgical localization), each 24 hours
Monitoring for localization of cerebral seizure focus by computerized portable 16 or more
channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours
ICD-9 Procedure
89.19
Video and radio-telemetered electroencephalographic monitoring
ICD-9 Diagnosis
345.00-345.91
347.00-347.11
348.30-348.39
Epilepsy
Cataplexy and narcolepsy
Encephalopathy, not elsewhere classified
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Coverage Guidelines take precedence
over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that
services are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in
adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
Page 2 of 5
© CPT Only – American Medical Association
Clinical UM Guideline
CG-MED-18
Electroencephalography (EEG) Testing: Ambulatory and Video
780.01-780.09
780.2
780.31-780.39
V12.54
Alteration of consciousness
Syncope and collapse
Convulsions
Personal history of transient ischemic attack (TIA), and cerebral infarction without
residual deficits
Discussion/General Information
A standard EEG, in most instances, can identify seizure activity. When a standard EEG is inconclusive and the
clinical history strongly suggests seizure activity, an ambulatory EEG may be indicated. This type of EEG testing is
a continuous recording that can range from several hours to three days. In the outpatient setting (e.g., physician
office, clinic) the electrodes are secured on the patient’s head and a recording unit is attached by a belt to the
patient’s waist or on a shoulder harness. The unit records the electrical activity while the patient continues activities
in the home environment. The information is analyzed at the end of the testing period. Ambulatory EEGs are useful
to capture recurrent or variable electrical activity that are more likely to occur in the patient’s home environment,
while the patient is awake or sleeping.
The video EEG is an EEG study that uses additional electrodes for EEG monitoring combined with simultaneous
video recording while the patient is awake or sleeping. This type of testing provides a visual study of the patient
during periods of abnormal activity identified by EEG monitoring. It is performed when the physician needs to link
a specific “spell” with the presence or absence of an abnormal EEG (brain wave) pattern. This is used to make a
distinction between seizures vs. non-epileptic events, or to establish the type of seizure disorder. In addition, video
monitoring may be combined with an EEG in the selection of the appropriate patients when epilepsy surgery is
being considered. In some cases this may be accomplished during a 23 hour observation period; however other
patients may require a further period of in-patient observation in order to obtain sufficient information.
Cascino (2002) noted that for most patients who have epilepsy, a routine EEG is sufficient for classification of
seizure types and for initiation of medical therapy. Routine EEG testing has substantial limitations for
approximately 20% of patients who do not have epilepsy but are referred for comprehensive evaluation because of
medically refractory "seizures." These patients may have physiological or psychological disorders that may cause
diagnostic confusion with epilepsy and result in the patients being treated unnecessarily with antiepileptic drugs.
Video-EEG monitoring can facilitate identification of EEG patterns for classifying seizure types and determining
surgical localization.
Olson (2001) reviewed ambulatory EEGs (AEEG) of 167 inpatient children when seizure like events occurred at
least 3 days per week, to determine why the AEEGs were performed and whether typical seizures were recorded.
Most AEEGs were performed to discriminate between epileptic and nonepileptic seizures. Ten were recorded to
determine whether they were having frequent subtle seizures or frequent interictal epileptiform discharges. The
remaining 157 patients had discrete events. A total of 140 children (89%) had their typical spells recorded. A total
of 107 of these children (76%) had non epileptic events. Average duration of recording was 1.9 days. AEEG was
very successful in recording children's seizure like events when parents report events occur at least 3 days per week.
The procedure is well tolerated and there are few technical problems that prolong recording time.
Lobello and colleagues (2006), in a retrospective study, reviewed medical records of 199 adult patients admitted for
having a behavioral event. The goal was to establish the number of days required to differentiate psychogenic non
epileptic seizures (PNES) and epileptic seizures (ES) based on video EEG monitoring. Results showed that 83.9%
(n = 167) had a clinical event during admission, and a definitive diagnosis was made in 75.9% (n = 151). Of
patients who had clinical events, 87.7% (n = 143) had their first event on admission day 1 or 2. Factors associated
with ES included an abnormal baseline EEG (P < 0.001), an abnormal brain MRI (P = 0.01), and history of events
lasting less than 1 minute (P = 0.01). There was no association between time to first event and discharge diagnosis.
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Coverage Guidelines take precedence
over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that
services are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in
adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
Page 3 of 5
© CPT Only – American Medical Association
CG-MED-18
Clinical UM Guideline
Electroencephalography (EEG) Testing: Ambulatory and Video
Video EEG monitoring differentiated between ES and PNES in the majority of adult patients evaluated. Most
behavioral events were characterized within 2 days of admission.
References
Peer Reviewed Publications:
1. Cascino, GD. Clinical indications and diagnostic yield of video-electroencephalographic monitoring in patients
with seizures and spells. Mayo Clin Proc. 2002; 77(10); 1111-1120.
2. Lobello K, Morgenlander JC, Radtke RA, Bushnell CD. Video/EEG monitoring in the evaluation of
paroxysmal behavioral events: duration, effectiveness and limitations. Epilepsy Behav. 2006; 8(1):261-266.
3. Mendiratta A. Clinical neurophysiology of epilepsy. Curr Neurol Neurosci Rep. 2003; 3(4):332-340.
4. Olson DM. Success of ambulatory EEG in children. J Clin Neurophysiol. 2001; 18(2):158-161.
5. Saravanan K, Acomb B, Beirne M, Appleton R. An audit of ambulatory cassette EEG monitoring in children.
Seizure. 2001; 10(8):579-582.
Government Agency, Medical Society and Other Authoritative Publications:
1. Agency for Heathcare Quality and Research. Management of Newly Diagnosed Patients with Epilepsy: A
Systematic Review of the Literature. Summary, Evidence Report/Technology Assessment: Number 39. AHRQ
Publication Number 01-E037, February 2001. Agency for Healthcare Research and Quality, Rockville, MD.
Available at: http://www.ahrq.gov/clinic/epcsums/epilepsum.htm Accessed on June 5, 2008.
2. Centers for Medicare and Medicaid Services. National Coverage Determination for Ambulatory EEG
Monitoring. NCD #160.22. Effective June 12, 1984. Available at:
http://www.cms.hhs.gov/mcd/index_chapter_list.asp. Accessed on June 5, 2008.
3. Centers for Medicare and Medicaid Services. National Coverage Determination for Telephone Transmission of
Electroencephalograms (EEGs). NCD #160.21. Effective date not posted. Available at:
http://www.cms.hhs.gov/mcd/index_chapter_list.asp . Accessed on June 5, 2008.
4. National Institute of Neurological Disorders and Stroke (NINDS). Seizures and Epilepsy: Hope Through
Research. 2004. Available at: http://www.ninds.nih.gov/disorders/epilepsy/detail_epilepsy.htm#toc. Accessed
on June 5, 2008.
Index
Ambulatory EEG
EEG
Electroencephalography
Video EEG
History
Status
Reviewed
Date
08/28/2008
Reviewed
Reviewed
08/23/2007
09/14/2006
11/22/2005
Revised
09/22/2005
Action
Medical Policy & Technology Assessment Committee (MPTAC) review.
Discussion/General Information, coding and references updated.
MPTAC review. Coding section and references updated.
MPTAC review. References updated.
Added reference for Centers for Medicare and Medicaid Services (CMS) –
National Coverage Determination (NCD).
MPTAC review. Revision based on Pre-merger Anthem and Pre-merger
WellPoint Harmonization.
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Coverage Guidelines take precedence
over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that
services are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in
adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
Page 4 of 5
© CPT Only – American Medical Association
CG-MED-18
Clinical UM Guideline
Electroencephalography (EEG) Testing: Ambulatory and Video
Pre-Merger
Organizations
Anthem, Inc.
Anthem BCBS
WellPoint Health
Networks, Inc.
Last Review
Date
Document
Number
02/11/2005
MA-007
06/24/2004
Clinical
Guideline
Title
None
Video Monitored Electroencephalography
(EEG), (Noninvasive or Scalp Recorded
Video Monitored EEG)
Enhanced EEG Testing: Ambulatory and
Video
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Coverage Guidelines take precedence
over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that
services are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in
adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
Page 5 of 5
© CPT Only – American Medical Association