Anthem Blue Cross Connecticut CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring Form

This document addresses electroencephalography (EEG) with and without video monitoring in the ambulatory setting and attended video EEG in a healthcare facility.

Ambulatory EEG

Medically Necessary:

Ambulatory EEG with or without video monitoring is considered medically necessary for any of the following indications:

• To diagnose a seizure disorder when either the clinical history or examination is suggestive of epilepsy, but routine EEG is non-diagnostic; or
• To classify seizure type in individuals with epilepsy after a routine EEG is non-diagnostic and classification will be used to select drug therapy; or
• To differentiate between paroxysmal non-epileptic events and seizures; or
• To document seizures precipitated by naturally occurring cyclic events or extraneous stimuli (for example, flashing lights, loud sounds, sudden movements) that are not reproducible in the hospital or laboratory setting; or
• To evaluate seizures or syncope suspected to be cardiogenic in etiology when cardiac evaluation has not been diagnostic; or
• To quantify the number of electrical seizures in individuals who experience frequent seizures.

Not Medically Necessary:

Ambulatory EEG with or without video monitoring is considered not medically necessary in all of the following circumstances including, but not limited to:

• Use in unattended, uncooperative individuals.
• Localization of seizure focus in individuals with medically refractory epilepsy who are candidates for epilepsy surgery.
• Antiseizure medication treatment withdrawal or modification in individuals where the risk of seizure precipitation would require immediate medical intervention.
• When an above criterion is not met.

Attended EEG Video Monitoring in a Healthcare Facility

Medically Necessary:

Attended EEG with video monitoring in a healthcare facility is considered medically necessary for any of the following indications:

• Antiseizure medication withdrawal or modification in individuals where risk of seizure precipitation would require immediate medical intervention; or
• Presurgical evaluation for epilepsy surgery for localization of epileptic foci; or
• Differentiating epileptic from nonepileptic seizures; or
• Status epilepticus; or
• Non-convulsive status epilepticus.

Not Medically Necessary:

Attended EEG with video monitoring in a healthcare facility is considered not medically necessary when an above criterion is not met and for all other indications.