Clinical Policy: Digital EEG Spike Analysis Form

CENTENE Corporation

Clinical Policy: Digital EEG Spike Analysis
Reference Number: CP.MP.105
Date of Last Revision: 09/25

See Important Reminder at the end of this policy for important regulatory and legal information.

Description

Electroencephalography (EEG) is a significant component of epilepsy diagnosis, along with a thorough medical history and neurological workup.¹ Most EEGs today are performed on digital machines, which record data and automatically detect spikes that may indicate seizures.² For the purpose of this policy, digital EEG spike analysis, also known as 3D dipole localization or dipole source imaging, refers to additional analysis of digitally recorded EEG spikes by a technician and a physician.

Policy/Criteria

I. It is the policy of health plans affiliated with Centene Corporation® that digital electroencephalography (EEG) spike analysis (CPT 95957), including topographic voltage and/or dipole analysis, is medically necessary for the pre-surgical evaluation of members/enrollees with intractable epilepsy, in conjunction with video EEG long-term monitoring.

II. It is the policy of health plans affiliated with Centene Corporation that digital EEG spike analysis (CPT 95957) is not medically necessary for any other indication.

Background

According to the American Clinical Neurophysiology Society’s (ACNS) Guidelines for Long Term Monitoring of Epilepsy, digital electroencephalography (EEG) is the industry standard. Ambulatory EEG, video EEG, and routine EEG all use digital technology and usually incorporate automatic spike detection.² However, these types of EEG analyses are not the same as digital EEG spike (3D dipole localization) analysis. Digital analysis of an EEG requires the analysis of an EEG using quantitative analytical techniques such as data selection, quantitative software processing, and dipole source analysis. Digital EEG spike analysis assessment and billing should not be used for cases when the EEG was only recorded on digital equipment. Digital EEG spike analysis assessment is reserved specifically for times when substantial additional digital analysis was medically necessary and was performed, such as 3D dipole localization, and is most commonly used at specialty centers.³

It is important to note that the ACNS specifically states that ambulatory EEG is not appropriate for detailed characterization of EEG features as is required in presurgical evaluation but may serve as useful triage function.² 3D spike dipole source analysis, or digital EEG spike analysis, has been shown to be concordant with other modes of presurgical evaluation of epilepsy, including a thorough neurological workup with video EEG, magnetic resonance imaging (MRI), and multiple other imaging and neuropsychological tests; electrocorticography; and magnetoencephalography.⁴ Studies have demonstrated “that dipole source models can be successfully employed to detect the epileptogenic foci of interictal epileptiform

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CENTENE Corporation

CLINICAL POLICY
Digital EEG Spike Analysis

Coding Implications

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Inclusion or exclusion of any codes in this policy does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

Table 1: Procedure codes that support medical necessity criteria when performed in conjunction with any of the following, and with a diagnosis in Table 2: 95718, 95720, 95722, 95724, 95726

| G40.019 | Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus |

| G40.111 | Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus |

| G40.119 | Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus |

| G40.211 | Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus |

| G40.219 | Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus |

| G40.311 | Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus |

| G40.319 | Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus |

| G40.411 | Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus |

| G40.419 | Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus |

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CENTENE Corporation

CLINICAL POLICY
Digital EEG Spike Analysis

Reviews, Revisions, and Approvals

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CENTENE Corporation

CLINICAL POLICY
Digital EEG Spike Analysis

Important reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as state and federal requirements and applicable Health Plan-level administrative policies and procedures.

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CENTENE Corporation

CLINICAL POLICY
Digital EEG Spike Analysis

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

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