Anthem Blue Cross Connecticut Commercial Clinical Policy

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



Ambulatory EEG

Indications

(77975) Is Ambulatory EEG being used to diagnose a seizure disorder when the clinical history or examination suggests epilepsy, but routine EEG is non-diagnostic? 
(77976) Is Ambulatory EEG being used to classify seizure type in individuals with epilepsy after a routine EEG is non-diagnostic and classification will be used to select drug therapy? 
(77977) Is Ambulatory EEG being used to differentiate between paroxysmal non-epileptic events and seizures? 
(77978) Is Ambulatory EEG being used to document seizures precipitated by naturally occurring cyclic events or extraneous stimuli that are not reproducible in the hospital or laboratory setting? 
(77979) Is Ambulatory EEG being used to evaluate seizures or syncope suspected to be cardiogenic in etiology when cardiac evaluation has not been diagnostic? 
(77980) Is Ambulatory EEG being used to quantify the number of electrical seizures in individuals who experience frequent seizures? 

Contraindications

(77981) Is Ambulatory EEG with or without video monitoring used in unattended, uncooperative individuals? 
(77982) Is the purpose of Ambulatory EEG localization of seizure focus in individuals with medically refractory epilepsy who are candidates for epilepsy surgery? 
(77983) Is Ambulatory EEG used during antiseizure medication treatment withdrawal or modification where the risk of seizure precipitation would require immediate medical intervention? 
(77984) Are none of the indications for Ambulatory EEG met? 

Attended EEG Video Monitoring in a Healthcare Facility

Indications

(77985) Is Attended EEG with video monitoring in a healthcare facility used during antiseizure medication withdrawal or modification where risk of seizure precipitation would require immediate medical intervention? 
(77986) Is it for presurgical evaluation for epilepsy surgery for localization of epileptic foci? 
(77987) Does the use involve differentiating epileptic from nonepileptic seizures? 
(77988) Is the patient experiencing status epilepticus? 
(77989) Is the patient experiencing non-convulsive status epilepticus? 

Contraindications

(77990) Is Attended EEG with video monitoring in a healthcare facility requested without meeting any of the above criteria? 
(77991) Is Attended EEG with video monitoring in a healthcare facility requested for an indication other than those specified above? 
Effective Date

09/27/2023

Last Reviewed

02/16/2023

Original Document

  Reference



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

Clinical Indications

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.