Anthem Blue Cross Connecticut CG-MED-76 Magnetic Source Imaging and Magnetoencephalography Form

Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses magnetic source imaging (MSI) and magnetoencephalography (MEG).

Note: Please see the following related document for additional information:

  • CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring

Clinical Indications

Medically Necessary:

Magnetoencephalography (MEG) is considered medically necessary for:

  1. Preoperative evaluation of individuals with intractable focal epilepsy to identify and localize area(s) of epileptiform activity when other techniques are indeterminate; or
  2. Preoperative localization of eloquent cortex prior to surgical resection of any of the following:
    1. Brain tumor in order to maximize preservation of eloquent cortex; or
    2. Vascular malformations in order to maximize preservation of eloquent cortex.

Magnetic source imaging (MSI) is considered medically necessary for:

  1. Preoperative evaluation of individuals with intractable focal epilepsy to identify and localize area(s) of epileptiform activity when other techniques are indeterminate; or
  2. Preoperative localization of eloquent cortex prior to surgical resection of any of the following:
    1. Brain tumor in order to maximize preservation of eloquent cortex; or
    2. Vascular malformations in order to maximize preservation of eloquent cortex.

Not Medically Necessary:

Magnetoencephalography (MEG) and magnetic source imaging (MSI) are considered not medically necessary for all other indications.