Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)

Policy #:07.03.10e

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.

MEDICALLY NECESSARY

Magnetoencephalography (MEG) with magnetic source imaging (MSI) is considered medically necessary and, therefore, covered as a method for determining the laterality of language function in individuals who are being prepared for surgery for epilepsy, brain tumors, and other indications requiring brain resection.

Magnetoencephalography (MEG) with magnetic source imaging (MSI) is considered medically necessary and, therefore, covered as part of the preoperative evaluation of individuals with intractable epilepsy to identify and localize areas of epileptiform activity, when standard techniques, such as MRI, are inconclusive.

EXPERIMENTAL/INVESTIGATIONAL

All other uses for MEG with MSI are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, magnetoencephalography (MEG) with magnetic source imaging (MSI) 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

The FDA has approved numerous devices to perform MEG.

Description

Magnetoencephalography (MEG) is a noninvasive functional imaging technique in which the weak magnetic forces associated with the electrical activity of the brain are recorded externally. Using mathematical modeling, the recorded data are then analyzed to provide an estimated location of the electrical activity. This information can be superimposed on an anatomic image of the brain, which is typically obtained via magnetic resonance imaging (MRI), to produce a functional/anatomic image referred to as magnetic source imaging (MSI). MSI differs from standard electroencephalography (EEG) in that it records magnetic fields instead of electrical activity. Although the conductivity, and thus measurement, of electrical activity recorded by an EEG is altered by surrounding brain structures, magnetic fields are not. Therefore, a high-resolution image is the primary advantage of MSI.

The technique is extremely sophisticated. Detection of the weak magnetic fields depends on gradiometer detection coils coupled to superconducting quantum interference devices (SQUIDs), which must be located in a specialized room to keep them shielded from other magnetic sources. Mathematical modeling programs based on idealized assumptions translate the detected signals into functional images. In its early evolution, the technique's clinical applications were limited by the use of only one detection coil, which required lengthy imaging times, and which, because of body movement, were also difficult to coordinate with the MRI. However, the technique has recently evolved to use an array of multiple detection coils capable of efficiently providing data over a wide extracranial region.

The most thoroughly studied clinical application of MEG with MSI involves localization of the pre- and post-central gyri as a guide to surgical planning in individuals who are scheduled to undergo neurosurgery for epilepsy, brain neoplasms, arteriovenous malformations, or other brain disorders. These gyri contain the "eloquent" sensorimotor areas of the brain, the preservation of which is considered critical during any type of brain surgery. In healthy individuals, these areas can be identified anatomically by MRI, but in affected individuals the anatomy is frequently distorted by underlying disease processes. In addition, the location of the eloquent functions is variable even among normal individuals. Therefore, localization of the eloquent cortex often requires invasive intraoperative functional techniques such as cortical stimulation under local anesthesia or somatosensory-evoked responses on electrocorticography (ECoG). Although these techniques can be done at the same time as the planned resection, they are cumbersome and can add up to 45 minutes of anesthesia time. Furthermore, these techniques can be limited by the small surgical field.

Another related clinical application of MEG with MSI involves localization of epileptic foci, particularly for the screening of surgical candidates and for surgical planning. Alternative techniques include MRI, positron emission tomography (PET), and single photon-emission computed tomography (SPECT) scanning. Anatomic imaging (ie, MRI) is effective when epilepsy is associated with a mass lesion (eg, tumor), vascular malformation, or hippocampal atrophy. If an anatomic abnormality is not detected, individuals may undergo a PET scan. In a small subset of individuals, extended ECoG and stereotactic EEG (SEEG) with implanted electrodes are considered the gold standards for localizing epileptic foci. MEG with MSI has principally been investigated as a supplement or an alternative to invasive monitoring.
References


Albert GW, Ibrahim GM, Otsubo H, et al. Magnetoencephalography-guided resection of epileptogenic foci in children. J Neurosurg Pediatr. 2014;14(5):532-537.

American Academy of Neurology Professional Association (AAON). Magnetoencephalography (MEG) Policy [AAON Web site]. 05/08/09. Available at: https://www.aan.com/practice/billing-and-coding/coverage-policies/. Accessed January 13, 2016.

Bagic AI, Barkley GL, Rose DF, et al. American Clinical Magnetoencephalography Society Clinical Practice Guideline 4: qualifications of MEG-EEG personnel. J Clin Neurophysiol. 2011;28(4):364-365.

Bagic AI, Bowyer SM, Kirsch HE, et al. American Clinical MEG Society (ACMEGS) Position Statement #2: The value of magnetoencephalography (MEG)/magnetic source imaging (MSI) in noninvasive presurgical mapping of eloquent cortices of patients preparing for surgical interventions. J Clin Neurophysiol. 2017;34(3):189-195.

Bagic AI, Funke ME, Ebersole J. American Clinical MEG Society (ACMEGS) position statement: the value of magnetoencephalography (MEG)/magnetic source imaging (MSI) in noninvasive presurgical evaluation of patients with medical intractable localization-related epilepsy. J Clin Neurophysiol. 2009;26(4):290-293.

Bagic AI, Knowlton RC, Rose DF, et al. American Clinical Magnetoencephalography Society Clinical Practice Guideline 1: recording and analysis of spontaneous cerebral activity. J Clin Neurophysiol. 2011;28(4):348-354.

Bagic AI, Knowlton RC, Rose DF, et al. American Clinical Magnetoencephalography Society Clinical Practice Guideline 3: MEG-EEG reporting. J Clin Neurophysiol. 2011;28(4):362-363.

Blue Cross Blue Shield Association Technology Evaluation Center (TEC). TEC Special Report: Magnetoencephalography and magnetic source imaging for the purpose of presurgical localization of epileptic lesions—a challenge for technology evaluation. TEC Assessments 2008; Volume 23, Tab 8.

Blue Cross Blue Shield Association Technology Evaluation Center (TEC). Magnetoencephalography (MEG) and magnetic source imaging (MSI): presurgical localization of epileptic lesions and presurgical function mapping. TEC Assessments 2003; Volume 18, Tab 6.

Burgess RC, Funke ME, Bowyer SM, et al. American Clinical Magnetoencephalography Society Clinical Practice Guideline 2: presurgical functional brain mapping using magnetic evoked fields. J Clin Neurophysiol. 2011;28(4):355-361.

De Tiege X, Carrette E, Legros B, et al. Clinical added value of magnetic source imaging in the presurgical evaluation of refractory focal epilepsy. J Neurol Neurosurg Psychiatry. 2012; 83(4):417-23.

Health Quality Ontario. Functional brain imaging: An evidence-based review. Ont Health Technol Assess Ser. 2006;6(22):1-79.

Hirata M, Kato A, Taniguchi M, et al. Determination of language dominance with synthetic aperture magnetometry: comparison with the Wada test. Neuroimage. 2004;23(1):46-53.

Kim H, Kankirawatana P, Killen J, et al. Magnetic source imaging (MSI) in children with neocortical epilepsy: surgical outcome association with 3D post-resection analysis. Epilepsy Res. 2013;106(1-2):164-172.

Knowlton RC, Elgavish RA, Limdi N, et al. Functional imaging: I. Relative predictive value of intracranial electroencephalography. Ann Neurol. 2008;64(1):25-34.

Knowlton RC, Razdan SN, Limdi N, et al. Effect of epilepsy magnetic source imaging on intracranial electrode placement. Ann Neurol. 2009;65(6):716-723.

Lau M, Yam D, Burneo JG. A systematic review on MEG and its use in the presurgical evaluation of localization-related epilepsy. Epilepsy Res. 2008;79(2-3):97-104.

Nirajan A, Laing EJ, Laghari FJ, et al. Preoperative magnetoencephalographis sensory cortex mapping. Stereotact Funct Neurosurg. 2013;91(5):314-322.

Papanicolaou AC, Simos PG, Castillo EM, et al. Magnetocephalography: a noninvasive alternative to the Wada procedure. J Neurosurg. 2004;100(5):867-876.

Schneider F, Irene Wang Z, Alexopoulous AV, et al. Magnetic source imaging and total SPECT in MRI - negative neocortial epilepsies: additional value and comparison with intracranial EEG. Epilepsia. 2013;54(2):359-369.

Sutherling WW, Mamelak AN, Thyerlei D, et al. Influence of magnetic source imaging for planning intracranial EEG in epilepsy. Neurology. 2008;71(13):990-6.

Tarapore PE, Tate MC, Findlay AM, et al. Preoperative multimodal motormapping: a comparason of magnetoencephalography imaging, navigated transcranial magnetic stimulation, and direct cortical stimulation. J Neurosurg. 2012; 117(2): 354-362.

Wang Y, Liu B, Fu L, et al. Use of interictal (18)F-fluorodeoxyglucose (FDG)-PET and magnetoencephalography (MEG) to localize epileptogenic foci in non-lesional epilepsy in a cohort of 16 patients. J Neurol Sci. 2015;355(1-2):120-124.

Widjaja E, Shammas A, Vali R et al. FDG-PET and magnetoencepahalography in presurgical work up of children with localization-related nonlesional epilepsi. Epilepsia.2013; 54 (4): 691-699.





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)

95965; 95966; 95967


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)

S8035 Magnetic source imaging


Revenue Code Number(s)



0860 Magnetoencephalography (MEG): General Classification

0861 Magnetoencephalography (MEG): MEG

Coding and Billing Requirements



Policy History

Revisions from 07.03.10e:
11/21/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI).

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/28/2015
Version Issued Date: 01/28/2015
Version Reissued Date: 11/21/2018

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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.