Notification

Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home


Notification Issue Date: 03/30/2018

This version of the policy will become effective 04/30/2018.

The following new policy has been developed to communicate the Company’s coverage criteria for Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home.



Medical Policy Bulletin


Title:Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home

Policy #:07.03.25

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

INPATIENT MONITORING

Video EEG monitoring in the inpatient setting (95951) is considered medically necessary and, therefore, covered for any of the following indications:
  • EEG recording during withdrawal of anti-seizure medications, which can be safely undertaken only in the immediate proximity of emergency medical personnel and technology
  • EEG recording attempting to localize the seizure focus prior to surgery
  • EEG recording after a negative ambulatory EEG and continuing episodes of suspected seizure activity

HOME MONITORING

Ambulatory EEG monitoring with or without video (95950 or 95953) in the home setting is considered medically necessary and, therefore, covered when any of the following criteria are met:
  • To evaluate inconclusive routine “resting” EEGs
  • To evaluate the occurrence of episodic events where epilepsy is suspected but the history, examination, and routine EEG recordings do not resolve the diagnostic uncertainties
  • To evaluate the occurrence of suspected nonepileptic events in an individual with confirmed epilepsy or for classification of seizure type (only ictal recordings can reliably be used to classify seizure type (or types) which is important in selecting appropriate antiepileptic drug therapy)
  • To differentiate between neurological, cardiac, and psychiatric related disorders
  • To localize seizure focus for enhanced management
  • To identify and medicate absence seizures
  • To evaluate the occurrence of suspected seizures of sleep disturbances
  • To evaluate seizures which are precipitated by naturally occurring cyclic events or environmental stimuli which are not reproducible in the hospital or clinic setting

All other uses for ambulatory electroencephalogram (EEG) monitoring and video EEG monitoring are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis of illness or injury.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Video EEG monitoring in the inpatient setting should be reported using the following code: 95951.

Ambulatory EEG monitoring in the home setting should be reported using one of the following codes: 95950 or 95953.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, continuous electroencephalogram (EEG) monitoring is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for EEG monitoring.

Description

An electroencephalogram (EEG) is a diagnostic test that measures the electrical activity of the brain (brainwaves) using highly sensitive recording equipment attached to the scalp by fine electrodes. It is used to diagnose neurological conditions.

EEGs can be recorded by 24-hour ambulatory cassette or digital recorders and offer the ability to record the EEG on a long-term outpatient basis. Ambulatory EEG monitoring is accomplished by a recorder that continuously records brain wave patterns during 24 hours of an individual’s routine daily activities and sleep. The monitoring equipment consists of an electrode set, preamplifiers, and a recorder. The electrodes attach to the scalp, and their leads are connected to a recorder, usually worn on a belt. Ambulatory monitoring is not necessary to evaluate most seizures, which are usually readily diagnosed by routine EEG studies, physical examination and history.

Ambulatory EEG monitoring is, however, a diagnostic procedure for individuals in whom a seizure diathesis is suspected but not defined by history, physical examination, or resting EEG. Ambulatory EEG monitoring may facilitate the differential diagnosis between seizures and syncopal attacks, sleep apnea, cardiac arrhythmias or hysterical episodes. The test may also allow the professional provider to identify the epileptic nature of some episodic periods of disturbed consciousness, mild confusion, or peculiar behavior, where resting EEG is not conclusive. Additionally, it may also estimate seizure frequency, which may at times help to evaluate the effectiveness of a drug and determine its appropriate dosage.

EEG video monitoring combines the simultaneous recording of the EEG and video monitoring of behavior. This allows for correlation of ictal and interictal electrical events with demonstrated or recorded seizure symptomology. The combination of electroencephalographic and video monitoring of an individual is useful in the initial diagnosis of epilepsy, particularly where previous attempts to define or characterize the seizure activity have proven inconclusive. Beyond the initial diagnosis of epilepsy, the combination is useful in uncharacterized events, identifying affected areas of the brain, and confirmation and/or differentiation between epileptic and nonepileptic events. Additionally, the study may be used in the pediatric population where history and clinical descriptions of seizure activity are difficult to obtain.

It is anticipated that clinical examination and routine electroencephalographic studies be utilized before employing electroencephalographic and video monitoring, and that this study be essential to the establishment of an appropriate treatment regimen.
References


American Clinical Neurophysiology Society. Guideline twelve: guidelines for long-term monitoring for epilepsy. J Clin Neurophysiol. 2008;25(3):170-80.

Benbadis SR. EEG Video Monitoring. [Medscape Web site]. 08/18/2016. Available at: http://emedicine.medscape.com/article/1137908overview. Accessed February 24, 2017.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).160.22: Ambulatory EEG monitoring. [CMS Web site]. Original: 6/12/1984. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?TAId=27&MEDCACId=18&NCAId=160&MCDId=11&ExpandComments=n&NCDId=215&ncdver=1&CALId=225&CalName=Prothrombin+Time+(PT)+NCD+190.17+(Addition+of+ICD-9-CM+diagnosis+code+197.7+Secondary+Malignant+Neoplasm+of+Liver)&CoverageSelection=National&ncd_id=20.20&ncd_version=2&basket=ncd%2525253A20%2525252E20%2525253A2%2525253AExternal+Counterpulsation+%25252528ECP%25252529+for+Severe+Angin&bc=gAAAABAAAAAAAA%3D%3D&. Accessed February 28, 2017.

Cascino GD. Surgical treatment of epilepsy in adults. 05/12/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed June 20, 2017.

Choi H, Mendiratta A. Seizures and epilepsy in older adults: Etiology, clinical presentation, and diagnosis. 05/12/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed June 20, 2017.

Goodwin E, Kandler RH, Alix JJ. The value of home video with ambulatory EEG: a prospective service review. Seizure. 2014;23(6):480-2.

Hirsch LJ, Haider HA, Moeller J. Video and ambulatory EEG monitoring in the diagnosis of seizures and epilepsy. 12/11/2015. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed February 27, 2017.

Nickels KC. Routine versus extended outpatient EEG: too short, too long, or just right? Epilepsy Curr. 2016;16(6): 382–383.

Schachter SC. Evaluation and management of the first seizure in adults. 02/21/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed June 20, 2017.

Schachter SC. Overview of the management of epilepsy in adults. 05/15/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed June 20, 2017.

St. Louis, EK, Frey, LC (Eds.). Electroencephalography (EEG): An introductory text and atlas of normal and abnormal findings in adults, children and infants. Chicago, IL: American Epilepsy Society; 2016.

Wilfong A. Epilepsy syndromes in children. 09/28/2016. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed June 20, 2017.

Wilfong A. Seizures and epilepsy in children: Refractory seizures and prognosis. 05/30/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed June 20, 2017.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

THE FOLLOWING CODE IS USED TO REPRESENT VIDEO EEG MONITORING IN THE INPATIENT SETTING: 95951

THE FOLLOWING CODES ARE USED TO REPRESENT AMBULATORY EEG MONITORING WITH OR WITHOUT VIDEO IN THE HOME SETTING: 95950, 95953


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

07.03.25
04/30/2018This new policy was been issued to communicate the Company's coverage position for Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home.

Version Effective Date: 04/30/2018
Version Issued Date: 04/30/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.