Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures Form

Effective Date

09/27/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses the use of a ketogenic diet to assist in the treatment of seizures.

Clinical Indications

Medically Necessary:

The use of a ketogenic diet for children and teenagers with seizures refractory to antiepileptic drugs is considered medically necessary.

Not Medically Necessary:

The use of a ketogenic diet for all other indications is considered not medically necessary.