Highmark Medicare Advantage Medical Policy in West Virginia
Section: Diagnostic Medical
Number: M-1
Topic: Special Electroencephalography
Effective Date: June 18, 2011
Issued Date: June 4, 2012

General Policy

For services prior to June 18, 2011, see policy N-128.

Ambulatory, or 24-hour electroencephalographic (EEG) monitoring is accomplished by a cassette recorder that continuously records brain wave patterns during 24 hours of a patient's routine daily activities and sleep. The monitoring equipment consists of an electrode set, preamplifiers, and a cassette recorder. The electrodes attach to the scalp, and their leads are connected to a recorder, usually worn on a belt.

Indications and Limitations of Coverage

Monitoring for identification and lateralization of cerebral seizure foci by ambulatory or continuous 24-hour Electroencephalogram (EEG) may be necessary in patients where epilepsy is suspected but not confirmed by clinical manifestations or resting EEG. Ambulatory EEG (95950 or 95953) should always be preceded by an awake and sleep study. The combination of electroencephalographic and video monitoring (95951) of a patient is useful and medically necessary in the initial diagnosis of epilepsy, particularly where previous attempts to define or characterize the seizure activity have proven inconclusive. It may also be medically necessary in the differentiation of psychogenic seizures from epilepsy and in the localization of a seizure focus prior to a surgical intervention for intractable epilepsy. It is anticipated that clinical examination and routine electroencephalographic studies be utilized before employing electroencephalographic and video monitoring, and that this study be essential to the establishment of an appropriate treatment regimen. Additionally, the study may be used in the pediatric population where history and clinical descriptions of seizure activity are difficult to obtain. It is anticipated that many of these outpatient studies will not provide the diagnosis within the first 24 hours, but it is expected that 72 hours of monitoring will be diagnostic in most circumstances. Occasionally patients may require more extensive monitoring, and medical necessity must be documented for review in these circumstances. This 72-hour limitation does not apply to the inpatient setting where patients are frequently withdrawn from their anti-epileptic regimens, and where precise presurgical localization of epileptic foci is often conducted.

It is anticipated that once the diagnosis has been established, this study will not be repeated, nor will it be used in the monitoring of a therapeutic regimen. Again, this expectation will not be applied to patients readmitted for inpatient care of their seizure disorder.

Reasons for Noncoverage

It would not be expected to see more than three services (three of one or three of any combination of services) billed in most circumstances within a one-year period.

It is anticipated that once the diagnosis has been established, this study will not be repeated, nor will it be used in the monitoring of a therapeutic regimen. As stated above, this expectation will not be applied to patients readmitted for inpatient care of their seizure disorder.

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record and made available upon request.

Monitoring beyond 72 hours must be supported by written documentation for each additional 24 hours of monitoring and be made available upon request.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

959509595195953   

Coding Guidelines

Publications

References

Medicare Benefit Policy Manual - Pub. 100-02.

Medicare National Coverage Determinations Manual - Pub. 100-03, Part 2, Section 160.22.

Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. 100-09, Chapter 5.

Social Security Act (Title XVIII) Standard References, Sections:

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

Covered Diagnosis Codes

300.11345.00-345.01345.10-345.11345.2-345.3
345.40-345.41345.50-345.51345.70-345.71345.80-345.81
345.90-345.91426.9780.2780.33
780.39   

ICD-10 Diagnosis Codes

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.