Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Form

MEDICAL COVERAGE POLICY SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Policy Number: 013 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 1 of 10 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy. SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) PRIOR AUTHORIZATION: Required. POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for coverage details. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) or LCD (Local Coverage Determination). If there are no applicable NCD or LCD criteria, use the criteria set forth below. For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. BSWHP may consider surgical intervention by cerebral hemispherectomy, corpus callosotomy, and temporal lobectomy medically necessary when ALL of the following criteria are met:

1. Member is at least 18 years old OR under 18 years of age with a suitable pediatric seizure diagnosis (e.g., unilateral multi-focal epilepsy associated with infantile hemiplegia as seen in hemimegaloencephaly and Sturge-Weber disease); AND
2. Non-epileptic events or conditions such as cardiogenic syncope and psychogenic seizures have been ruled out; AND
3. The diagnosis of epilepsy has been documented, and the epileptic seizure type and the epileptic syndrome has been clearly defined; AND
4. Seizures occur at a frequency that interferes with members' daily living and threatens their well- being; AND
5. There has been an adequate trial of drug therapy, with at least two appropriate antiepileptic medications at therapeutic levels, and with member compliance OR member has failed at least two drug therapies due to medication toxicity / adverse effects; AND
6. The individual is not a candidate for OR has failed invasive neurostimulation therapy.

MEDICAL COVERAGE POLICY SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Policy Number: 013 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 2 of 10 BSWHP may consider laser interstitial thermal therapy (LITT) and magnetic resonance-guided laser interstitial thermal therapy (e.g. NeuroBlate and Visualase Thermal Therapy System) medically necessary when ALL of the above surgical intervention criteria are met AND the following criteria are met:

1. There are LITT accessible well-defined epileptogenic foci; AND
2. LITT is determined to be the best treatment option by a multidisciplinary physician team of at least two specialties (e.g., neurosurgery, neurology) BSWHP may consider bilateral stimulation of the anterior nucleus of the thalamus (e.g., Medtronic DBS System for Epilepsy) medically necessary when ALL of the following criteria are met:
3. Member is at least 18 years old; AND
4. The diagnosis of partial onset seizure with or without secondary generalization to tonic-clonic activity is documented; AND
5. There has been an adequate trial of drug therapy, with at least three appropriate antiepileptic medications at therapeutic levels, and with member compliance OR member has failed at least three drug therapies due to medication toxicity / adverse effects; AND
6. Seizures occur at a frequency (average of at least 6 per month over the previous 3-month period, with no more than 30 days between seizures) that interferes with members' daily living and threatens their well-being. BSWHP may consider responsive neurostimulation (RNS) (e.g., the NeuroPace RNS System) medically necessary for adults with intractable focal aware seizures (partial onset seizures) when the following criteria are met:
7. Member is at least 18 years old; AND
8. Non-epileptic events or conditions such as cardiogenic syncope and psychogenic seizures have been ruled out; AND
9. The diagnosis of epilepsy has been documented, and the epileptic seizure type and the epileptic syndrome has been clearly defined; AND
10. Seizures (e.g., motor partial seizures, complex partial and/or secondarily generalized seizures) occur at a frequency (average of 3 per month over the previous 3-month period) that interferes with members' daily living and threatens their well-being; AND
11. There has been an adequate trial of drug therapy, with at least two appropriate antiepileptic medications at therapeutic levels, and with member compliance: AND
12. The member has no more than two epileptogenic regions; AND
13. Member is not a candidate for resective epilepsy surgery because epileptic focus is near regions of concern e.g., language or memory; AND
14. Member has ability, or has the necessary assistance, to properly operate the device; AND

MEDICAL COVERAGE POLICY SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Policy Number: 013 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 3 of 10

9. Member has none of the following contraindications:  Three or more specific seizure foci  Presence of generalized epilepsy  Presence of rapidly progressive neurologic disorder  Presence of other implanted medical devices that deliver electrical energy to the brain RNS is considered experimental, investigational, or unproven for all other indications. Vagus Nerve Stimulation (non-responsive or open loop)
10. For Medicare plans, please review using criteria set forth in NCD 160.18 Vagus Nerve Stimulation (VNS).18. Medicare NCD or LCD specific InterQual criteria may be used when available. If there are no applicable NCD or LCD criteria, use the criteria set forth below.
11. For all other plans, BSWHP may consider vagus nerve stimulation (non-responsive or open loop) medically necessary for epilepsy when the following criteria are met: a. There has been an adequate trial of drug therapy, with at least two appropriate antiepileptic medications at therapeutic levels, and with member compliance OR member has failed at least two drug therapies due to medication toxicity / adverse effects; AND b. Member does not have contraindication to vagus nerve stimulation (e.g., history of left or bilateral cervical vagotomy). Responsive (closed loop) and transcutaneous (non-implantable) vagus nerve stimulation devices are unproven and not medically necessary due to insufficient evidence of efficacy. Cerebral hemispherectomy, corpus callosotomy, and temporal lobectomy are considered experimental and investigational when selection criteria are not met. Cerebellar stimulation or deep brain stimulation for members with intractable seizures are considered experimental and investigational because their effectiveness for this indication has not been established. Localized neocortical resections are considered experimental and investigational for uncontrolled complex partial seizures because its effectiveness has not been established. Hippocampal electrical stimulation for the treatment of mesial-temporal lobe epilepsy is considered experimental and investigational because its effectiveness has not been established. The use of stereotactic radiosurgery including radiofrequency amygdalohippocampectomy for medial temporal lobe epilepsy and epilepsy arising in other functional cortical regions is considered experimental and investigational because its effectiveness has not been established.

MEDICAL COVERAGE POLICY SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Policy Number: 013 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 4 of 10 High-Frequency Oscillations in epilepsy surgery planning is considered experimental and investigational because its effectiveness has not been established. BSWHP requires prior authorization for all procedures as well as for planning procedures if epilepsy surgery is under consideration. Only evidence-based services as outlined in this policy will be authorized. BACKGROUND: Patients who have intractable epileptic seizures despite adequate treatment with appropriate antiepileptic drugs, can be offered relief with neurostimulators or surgery. The goal of invasive treatments for intractable seizures is to decrease the frequency of seizures and improve quality of life. Deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS) and vagus nerve stimulation has been found to be safe and effective for treating specific seizure types. Temporal lobectomy has been found to be safe and effective for treating patients with complex partial seizures of temporal or extratemporal origin. Patients who have a single identifiable focus in a restricted cortical area that can be safely excised without producing additional disability can be considered as candidates for temporal lobectomy. Corpus callosotomy is a palliative disconnection procedure that has been found to be safe and effective for reducing generalized seizures, particularly drop attacks (tonic and atonic seizures), in patients with drug-resistant generalized or multifocal epilepsy who are not candidates for focal resective surgery. Cerebral hemispherectomy (hemispherotomy) is a well-established, effective procedure for managing drug-resistant hemispheric epilepsy. The 2026 American Epilepsy Society guideline reports that hemispherectomy decreases the chance of failure to achieve seizure freedom (RR 0.32, NNT 1.42) and describes substantial benefits including high rates of seizure freedom and potential long-term seizure control. Indications include hemimegalencephaly, Sturge-Weber syndrome, Rasmussen encephalitis, perinatal stroke, cortical dysplasia, and other etiologies of unilateral hemispheric epilepsy. The best outcomes have been reported for Rasmussen encephalitis and Sturge-Weber syndrome Candidates for invasive management of epilepsy and their family, if applicable, should receive detailed information regarding the specific surgical procedures and their possible benefits and side effects. Candidates should not have co-existent progressive neurological disease or major psychological or medical disorder. Persons with progressive neurological diseases or major medical or psychological disorders are generally unsuitable candidates for invasive treatments for epilepsy because of the possibility that surgery could worsen the course of these other conditions.

MEDICAL COVERAGE POLICY SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Policy Number: 013 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 5 of 10 MANDATES: None CODES: Important note: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes 61534 - Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery 61536 - Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array) 61537 - Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, without electrocorticography during surgery 61538 - Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with electrocorticography during surgery 61541 - Craniotomy with elevation of bone flap; for transection of corpus callosum 61543 - Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy 61736 - Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion 61737 - Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesion(s) 61850 - Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical 61860 - Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical 61863 - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array 61864 - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure) 61880 - Revision or removal of intracranial neurostimulator electrodes 61885 - Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 61886 - Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays 61888 - Revision or removal of cranial neurostimulator pulse generator or receiver 64568 - Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 64569 - Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode

MEDICAL COVERAGE POLICY SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Policy Number: 013 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 6 of 10 array, including connection to existing pulse generator 64570 - Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 64999 - Unlisted procedure, nervous system CPT Codes Not Covered N/A ICD-10 Codes G40.011 - Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus G40.019 - Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus G40.111 - Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus G40.119 - Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus G40.211 - Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus G40.219 - Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus G40.311 - Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus G40.319 - Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus G40.411 - Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus G40.419 - Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus G40.803 - Other epilepsy, intractable, with status epilepticus G40.804 - Other epilepsy, intractable, without status epilepticus G40.811 - Lennox-Gastaut syndrome, not intractable, with status epilepticus G40.813 - Lennox-Gastaut syndrome, intractable, with status epilepticus G40.814 - Lennox-Gastaut syndrome, intractable, without status epilepticus G40.823 - Epileptic spasms, intractable, with status epilepticus G40.824 - Epileptic spasms, intractable, without status epilepticus G40.911 - Epilepsy, unspecified, intractable, with status epilepticus G40.919 - Epilepsy, unspecified, intractable, without status epilepticus

MEDICAL COVERAGE POLICY SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Policy Number: 013 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 7 of 10 POLICY HISTORY: Status Date Action New 12/17/2010 New policy Reviewed 12/17/2011 Reviewed. Reviewed 11/15/2012 Reviewed. Reviewed 11/14/2013 ICD10 codes added. Reviewed 09/25/2014 Reviewed Reviewed 09/24/2015 No changes Reviewed 09/08/2016 No changes Reviewed 08/22/2017 Criteria for coverage of responsive cortical stimulation added. Reviewed 06/05/2018 No changes Reviewed 08/22/2019 Criteria language updated where necessary. Codes updated Reviewed 09/24/2020 Criteria updated. Re-formatted for SWHP/FIrstCare Reviewed 09/23/2021 No changes Reviewed 09/22/2022 Significant revisions Reviewed 11/29/2023 Formatting changes, added hyperlinks to NCD and TMPPM, beginning and ending note sections updated to align with CMS requirements and business entity changes Reviewed 03/11/2024 Corrected the Last Review dates and Next Review Dates and corrected the “For Medicaid Plans” section to utilize this Medical Policy if TMPPM does not have medical necessity guidance Reviewed 09/09/2024 Removed invalid codes from CPT codes list, added descriptors for codes, and minor formatting changes Reviewed 05/12/2025
No changes Reviewed 08/11/2025 Removed “Medicare NCD or LCD specific InterQual criteria may be used when available.” Reviewed 05/28/2026 Updated Background Section and references. REFERENCES: The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence related to this policy and may modify it at a later date based upon

MEDICAL COVERAGE POLICY SERVICE: Seizure Disorders: Invasive Treatments (Epilepsy Surgery) Policy Number: 013 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 8 of 10 the evolution of the published clinical evidence. Should additional scientific studies become available and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

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59. Freedman D, Babatunde I, Morgan RL, Abu-Sawwa R, Albert D, Behbahani M, Chapman K, Fecske E, Gaillard WD, Jones M, Meskis MA, Myers LS, Nye K, Oluigbo C, Pfeifer HH, Shellhaas RA, Thompson L, Weiner HL, Wusthoff CJ, Yozawitz E. American Epilepsy Society Clinical Practice Guideline: Infantile Epilepsy. Epilepsy Curr. 2026 Apr 8:15357597261433266. doi: 10.1177/15357597261433266. Epub ahead of print. PMID: 41969626; PMCID: PMC13061853. Note: Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan.
    RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs; and FirstCare CHIP is offered through FirstCare in the Lubbock Service Area.