Anthem Blue Cross Connecticut CG-SURG-91 Minimally Invasive Ablative Procedures for Epilepsy Form

This document addresses minimally invasive ablative procedures used in the treatment of medically refractory epilepsy in individuals with symptomatic localized epilepsy. Minimally invasive procedures have been proposed as a means to minimize or eliminate major craniotomy and bone flap incisions, decrease pain and down-time, preserve tissue and decrease neurocognitive adverse effects. These procedures utilize laser, radiofrequency, or cryotherapy techniques, in combination with stereotactic magnetic resonance imaging (MRI) guidance, for targeted ablation of the epileptogenic foci.

Note: This document does not address minimally invasive surgery to treat conditions other than epilepsy, including treatment of cancerous lesions.

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• CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures
• MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
• SURG.00007 Vagus Nerve Stimulation
• SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
• CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver

Clinical Indications

Medically Necessary:

The treatment of medically refractory epilepsy using stereotactic laser techniques (MRI-guided laser interstitial thermal ablation [MRIgLITT]), including stereotactic laser amygdalohippocampotomy (SLAH), is considered medically necessary when both of the following criteria are met:

1. Documented disabling seizures despite the use of two or more tolerated antiepileptic drug regimens; and
2. Documented presence of two or fewer well delineated epileptogenic foci accessible by laser.

The use of stereotactic radiofrequency thermocoagulation (RF-TC) in the treatment of hypothalamic hamartomas is considered medically necessary.

Not Medically Necessary:

The treatment of medically refractory epilepsy using stereotactic laser techniques or stereotactic radiofrequency thermocoagulation is considered not medically necessary when the criteria above have not been met.

Other minimally invasive procedures to treat medically intractable epilepsy are considered not medically necessary, including but not limited to stereotactic radiofrequency amygdalohippocampectomy, sEEG-guided radiofrequency thermocoagulation or stereotactic cryosurgery.