Anthem Blue Cross ConnecticutCommercial Clinical Policy

CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures Form

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Ketogenic Diet for Treatment of Intractable Seizures

Indications

(539490) Is the ketogenic diet being considered for a child or teenager with seizures that are refractory to antiepileptic drugs? 

Contraindications

(539491) Is the ketogenic diet being used for indications other than intractable seizures in children and teenagers? 
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.