Video Electroencephalographic (EEG) Monitoring/media/c2ecafe850fa4bdd8f29ab45430d12b8.pdfVideo...

Video Electroencephalographic (EEG) Monitoring

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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bmchp.org | 888-566-0008 wellsense.org | 877-957-1300 Medical Policy

Video Electroencephalographic (EEG) Monitoring Policy Number: OCA 3.38 Version Number: 14 Version Effective Date: 08/01/16

Product Applicability

All Plan+ Products

Well Sense Health Plan New Hampshire Medicaid NH Health Protection Program

Boston Medical Center HealthNet Plan MassHealth Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options

only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary

Video electroencephalographic (EEG) monitoring is considered medically necessary when the test is used to evaluate known seizures, suspected seizures, involuntary episodes of movement, and/or altered level of consciousness after non-neurological causes of symptoms have been ruled out and Plan criteria are met. Video EEG monitoring is conducted when the adult or pediatric member’s diagnosis cannot be made by neurological examination, standard EEG studies, and ambulatory cassette EEG monitoring. Once the causes of seizures (or symptoms) and the specific type of epilepsy have been established, continued video EEG monitoring (e.g., monitoring the response to therapy or titrating medication dosages) is considered NOT medically necessary (when Plan criteria specified in this policy

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are not met); in these cases, response to therapy can be assessed using standard EEG monitoring or ambulatory EEG monitoring. Prior authorization is required for video EEG monitoring conducted in an observation setting or inpatient setting when the test is the reason for the inpatient admission. Video EEG monitoring conducted during an authorized inpatient stay does not require a separate prior authorization. It will be determined during the Plan’s prior authorization process if the service is considered medically necessary for the requested indication. See the Plan policy, Medically Necessary (policy number OCA 3.14), for the product-specific definitions of medically necessary treatment. See the applicable Plan medical policies and reimbursement guidelines available at www.bmchp.org for BMC HealthNet Plan products, including Reimbursement Guidelines - Observation Services (policy number 4.36). Review the applicable Plan medical policies and reimbursement guidelines available at www.wellsense.org for the Well Sense Health Plan products, including Reimbursement Guidelines - Hospital (policy number WS 4.21).

Description of Item or Service

Video Electroencephalographic (EEG): A diagnostic test that uses video and EEG recordings to continuously observe behavioral activity (i.e., seizure activity and/or involuntary episodes of movement or consciousness) while simultaneously recording electrical brain activity. Video EEG is used to diagnose seizure disorders, to classify seizure types and locations, and is used in the pre-surgical evaluation of intractable seizures. Medically refractory epilepsy is amenable to neurosurgical intervention if the epileptogenic focus is accurately localized. Video EEG monitoring is generally performed using external electrodes placed on the patient’s scalp surface to locate where seizures activity is originating; more invasive monitoring using intracranial electrode placement directly on the surface of the brain may be required to precisely map epileptic areas of the brain during video EEG monitoring. During testing, seizures may be provoked by antiepileptic medication withdrawal, sleep deprivation, or exercise, and then the individual is monitored. Long-term video EEG recordings (in an observation setting or inpatient setting) may be conducted to monitor and register member testing for 24 hours a day for 1 to 3 days (or longer with intracranial electrode placement, when medically necessary and Plan criteria are met).

Medical Policy Statement

Video electroencephalographic (EEG) monitoring is considered medically necessary when the following clinical presentation criteria (item A), duration of monitoring criteria (item B), and testing frequency criteria (item C) are met and documented in the member’s medical record for adult and pediatric members (including neonates and young children):



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A. Clinical Presentation Criteria:

1. A diagnosis cannot be made by neurological examination, standard EEG studies, and/or ambulatory cassette EEG monitoring and criteria are met for at least ONE (1) of the indications specified below in items a through d in this Clinical Presentation Criteria section:

a. Evaluation of Altered Level of Consciousness Without Confirmed Seizure Activity:

ALL of the following criteria are met, as specified below in items (1) through (4):

(1) Testing indication includes at least ONE (1) of the following, as specified below in item

(a) or item (b):

(a) Member is at risk for seizures based on clinical findings of elevated intracranial pressure or cerebral edema; OR

(b) Member has recurrent symptoms not classic for seizures and testing will be used

to differentiate epileptic events from psychogenic non-epileptic seizures (non-epileptic attack disorders) and quantify symptom frequency; AND

(2) History and lab tests are non-diagnostic for etiology of altered level of consciousness;

AND (3) Routine EEG results are nonspecific or the treating provider has provided medical

record documentation that a routine EEG is not medically necessary or not tolerated by the member (e.g., pediatric patient who cannot cooperate adequately for testing or a critically ill patient with conditions such as limbic encephalitis or frontal lobe seizures); AND

(4) For an adult member (i.e., an adult member is 21 years of age or older on the date of

service), the results of an MRI of the brain performed within the past 12 consecutive months is normal/non-diagnostic for etiology of altered level of consciousness; OR

(Note: MRI of the brain is not required for a pediatric member prior to video EEG monitoring but may be recommended by the treating provider; a pediatric member is less than 21 years of age on the date of service [i.e., until the member’s 21st birthday].)

b. Evaluation of Suspected Seizures (Including Involuntary Episodes of Movement):




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(1) Member has recurrent symptoms not classic for seizures, and testing will be used to differentiate epileptic events from psychogenic non-epileptic seizures (non-epileptic attack disorders) and quantify symptom frequency; AND

(2) History and lab tests are non-diagnostic for etiology of symptoms; AND (3) Routine EEG results are nonspecific or the treating provider has provided medical

record documentation that a routine EEG is not medically necessary or not tolerated by the member (e.g., pediatric patient who cannot cooperate adequately for testing or a critically ill patient with conditions such as limbic encephalitis or frontal lobe seizures); AND

(4) For an adult member, MRI of the brain performed within the past 12 consecutive

months is normal/non-diagnostic for etiology of symptoms (with an adult member defined as a member 21 years of age or older on the date of service); OR


c. Evaluation of Known Seizures:


(1) Routine EEG results are nonspecific; AND (2) For an adult member, MRI of the brain performed within the past 12 consecutive

months is normal/non-diagnostic for seizure etiology (with an adult member defined as a member 21 years of age or older on the date of service); AND


(3) Video EEG monitoring will be done to correctly classify seizure type and quantify seizure frequency in a member where such characterization is medically necessary to select the most appropriate therapeutic regimen; AND

(4) Results of video EEG monitoring will guide further treatment options in a member

with medically refractory seizure activity despite therapeutic antiepileptic drug levels;



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refractory to treatment is defined as ALL of the following, as specified below in items (a) through (c):

(a) ONE (1) of the following criteria is met, as specified below in item i (when

treatment with anticonvulsant medication is appropriate) or item ii (when medication trial is contraindicated):

i. Refractory to treatment with > 2 anticonvulsant medications attempted

and documented in the member’s medical record ; OR

ii. Medication trial is contraindicated for the member, as determined by the treating provider (e.g., member with status epilepticus or medication trial has caused worsening of EEG results); AND

(b) Member has had no sudden cessation of heavy alcohol use within 48 hours of

the seizure; AND (c) Member has no intoxication due to drugs of abuse within 48 hours of seizure;

OR d. Pre-surgical Evaluation:

(1) Video EEG monitoring will be used to localize the seizure focus in a member with refractory seizures prior to epilepsy surgery; AND

(2) Duration of monitoring criteria (item B below) are met; AND

(3) Testing frequency criteria (item C below) are met.

B. Duration of Monitoring Criteria:

When video EEG monitoring is medically necessary, this service is initially authorized in an observation setting. The treating provider must contact the Plan to obtain an additional authorization for an inpatient admission for video EEG monitoring at the time it is identified that 49 to 72 hours of monitoring is medically necessary within the same episode of care. ONE (1) of the following criteria must be met with each request for prior authorization, as specified below in item 1 or item 2: 1. Video EEG Monitoring Up to 48 Hours in an Observation Setting:

When Plan criteria are met, video EEG monitoring will be initially authorized in an observation setting; OR



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2. Video EEG Monitoring 49 Hours to 72 Hours in an Inpatient Setting:**

When video EEG monitoring is required beyond 48 hours, BOTH of the following criteria must be met, as specified below in item a and item b:

a. Plan prior authorization has been obtained for video EEG monitoring and has been conducted in an observation setting for this episode of care; AND

b. Additional time is required during this episode of care to evaluate the member’s symptoms

after 48 hours of observation.

** Note: The use of intracranial electronics with video EEG monitoring may require additional monitoring time when Plan medical criteria are met (until the causes of seizures, specific type of epilepsy, and response to therapy have been safely established). Video EEG monitoring conducted during an authorized inpatient stay does not require a separate prior authorization for the video EEG monitoring.

C. Testing Frequency Criteria:

At least ONE (1) of the following criteria is met, as specified below in items 1 through 3:

1. Video EEG monitoring will be conducted for a diagnostic purpose, and the adult member or

pediatric member has not had the test performed within the past 12 consecutive months; OR 2. Video EEG monitoring will be conducted to assist with treatment adjustment, and the adult

member or pediatric member has not had the test performed more than twice within the past 12 consecutive months; OR

3. The pediatric member, age less than 21 years old on the date of service (i.e., until the member’s

21st birthday) and has at least ONE (1) of the following conditions, as specified below in items a through c:

a. Epileptic encephalopathy (e.g., Landau-Kleffner syndrome or syndrome of continuous spikes

and waves during slow-wave sleep); OR

b. Infantile spasms refractory to treatment; OR

c. Recurrent status epilepticus



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Limitations

1. When Plan criteria are met for video EEG monitoring (in an observation setting which may not

exceed 48 hours or in an inpatient setting), the following prior authorization guidelines and considerations apply, as specified below in items a, b, and c:

a. The Plan will pre-authorize a total of three (3) inpatient days for eligible members if the

applicable criteria are met, as specified in the Medical Policy Statement section. b. Up to two (2) additional days for medication management and/or titration of medication

dosages for video EEG monitoring are considered medically necessary when at least ONE (1) of the following criteria is met, as specified below in item (1) or item (2): (1) There is documentation of infrequent or insufficient EEG changes; OR (2) The presence of EEG changes is indicative of seizure activity without clinical

manifestations of this activity. c. Other factors may influence the length of monitoring and require Plan Medical Director

review, including ANY of the following, as specified below in items (1) through (4):

(1) The overall impact and sequential timing of antiepileptic drug discontinuation; OR (2) Patient comorbidities; OR

(3) The need to capture at least three (3) events in the evaluation of patients for epilepsy

surgery; OR

(4) The use of intracranial electrodes during video EEG monitoring.

2. Home video EEG monitoring/ambulatory EEG monitoring in the home setting is considered experimental and investigational.

3. Video EEG monitoring conducted in an outpatient setting (other than in an observation setting)

is considered experimental and investigational due to the limited amount of time to evaluate the member’s symptoms during monitoring.

4. Contraindications to treatment include at least ONE (1) of the following, as specified below in

items a through d:

a. Concurrent use of seizure-provoking medication; OR



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b. Sudden cessation of heavy alcohol use within 48 hours of a seizure; OR c. Intoxication due to drugs of abuse within 48 hours of a seizure; OR

d. Testing of unattended member and/or non-cooperative member.

5. Limitations on testing frequency include ANY of the following, as specified below in item a or

item b: a. A request for video EEG monitoring conducted for a diagnostic purpose requires Plan

Medical Director review when the testing is more frequent than once in a 12-consecutive-month period; OR

b. A request for video EEG monitoring conducted for treatment adjustment requires Plan

Medical Director review when the testing is more frequent than twice within a 12-consecutive-month period.

6. The Plan considers video EEG monitoring experimental and investigational for all other

indications (e.g., assessment of the effectiveness of drug treatment in epilepsies, prognosis of cardiac arrest treated with hypothermia, and/or prognosis of newborns with hypoxic-ischemic encephalopathy treated with hypothermia) because its effectiveness for these indications has not been established.

Definitions

Ambulatory 24-Hour Electroencephalography (EEG) Monitoring: A diagnostic test that is used to record the electrical activity of the brain on a continuous outpatient basis for 24 hours. Scalp electrodes are secured to the patient’s head along with a digital or cassette recorder that is secured to the patient’s waist or via shoulder harness. The EEG information is stored in the recorder for analysis. An ambulatory EEG monitor has the ability to continuously record any seizure activity over a period of 24 hours. (See the Limitations section of this policy for limitations related to ambulatory EEG monitoring.) Electroencephalography (EEG): A diagnostic test that measures the electrical activity of the brain using scalp electrodes attached to sensitive recording equipment. A typical EEG takes about 90 minutes. Epileptic Encephalopathy: A heterogeneous group of epilepsy syndromes associated with severe cognitive and behavioral disturbances. These disorders vary in their age of onset, developmental outcome, etiologies, neuropsychological deficits, electroencephalographic (EEG) patterns, seizure types, and prognosis, but all may have a significant impact on neurological development and are believed to contribute to a progressive disturbance in cerebral function. This category includes the following epilepsy syndromes: early myoclonic encephalopathy, early infantile epileptic



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encephalopathy (Ohtahara syndrome), infantile spasm (IS or West syndrome), severe myoclonic epilepsy in infancy (Dravet syndrome), migrating partial seizures in infancy, myoclonic status in non-progressive encephalopathy, Lennox-Gastaut syndrome (LGS), Landau-Kleffner syndrome (LKS), and/or epilepsy with continuous spike-waves during slow wave sleep (CSWS). Infantile Spasm (IS) or West Syndrome: One of the most recognized types of epileptic encephalopathy, it is a distinct and often catastrophic form of epilepsy of early infancy. The disorder presents with a unique seizure type, infantile spasms, which are characterized by flexor, extensor, and mixed flexor-extensor spasms and frequently occur in clusters. Status Epilepticus: A common, life-threatening neurologic disorder that is essentially an acute, prolonged epileptic crisis. Status epilepticus can represent an exacerbation of a preexisting seizure disorder, the initial manifestation of a seizure disorder, or an insult other than a seizure disorder. In patients with known epilepsy, the most common cause is a change in medication. Most seizures terminate spontaneously.

Applicable Coding

The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Because the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service. Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member.

CPT Codes Description: Code Covered When Medically Necessary

95951 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (e.g., for pre-surgical localization), each 24 hours

http://emedicine.medscape.com/article/1176431-overview







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Clinical Background Information

Epilepsy is a recurrent paroxysmal disorder of cerebral function that is associated with a sudden and brief attack of altered consciousness, motor activity, or sensory phenomena. Convulsive seizures are the most common form of epilepsy. Epilepsy can be the result of injury, infection, structural abnormalities in the brain, abnormal fetal brain development, or exposure to toxins, but in many cases the cause is unknown. Seizures have been defined as paroxysmal disorder of the central nervous system that is associated with abnormal cerebral neuronal discharge, with or without loss of consciousness. Seizures have been further sub-classified into those with a generalized onset, beginning throughout the brain, and those with a partial onset, having a discrete focal onset. EEG, computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) scans are common diagnostic tests for epilepsy. Video EEG monitoring is used in clinical practice to verify the diagnosis and type of seizure and to localize the area of seizure foci if epilepsy surgery is being considered. Video EEG monitoring consists of the simultaneous recording of EEG brain wave activity combined with a time-synchronized video recording of the patient. This procedure is performed on an inpatient monitoring unit or observation unit and requires specialized equipment. Patients are monitored for several hours a day in order to capture any seizure events on video, and at the same time to capture EEG activity during the event. The duration of video EEG monitoring depends upon the frequency of the patient’s symptoms but generally can be completed within one (1) to three (3) days; testing is conducted in an observation setting or an inpatient setting (when additional time is medically appropriate). Factors that may influence the length of monitoring include the following: infrequent or insufficient EEG changes, the overall impact and sequential timing of antiepileptic drug discontinuation, the presence of EEG changes indicative of seizure activity without clinical manifestations of this activity, and/or patient comorbidities. Synchronized recordings of the patient’s behavior can contribute significantly to the diagnosis, as video recordings of the patient during and after a seizure are useful. For most patients who have epilepsy, the routine EEG or 24 ambulatory EEG test is sufficient for physicians to evaluate the type of seizure and initiate medical therapy. At the time of the Plan’s most recent policy review, no clinical guidelines were found from the Centers for Medicare & Medicaid Services (CMS) for video EEG monitoring. Determine if applicable CMS criteria are in effect for this service in a national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request for a Senior Care Options member.

References

Alving J, Beniczky S. Diagnostic usefulness and duration of the inpatient long-term video-EEG monitoring: Findings in patients extensively investigated before the monitoring. Seizure. 2009;18(7):470-473.



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American Academy of Neurology Guideline: Assessment of Digital EEG, Quantitative EEG, and EEG Brain Mapping: Report of the American Academy of Neurology and American Clinical Neurophysiology Society. 1997. Current as of May 6, 2012. Accessed at: http://www.acns.org/practice/guidelines or https://www.aan.com/ American Academy of Neurology Practice Parameter: Treatment of the Child with a First Unprovoked Seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology Society. Current as of May 6, 2012 . Accessed at: www.neurology.org and http://www.neurology.org/content/60/2/166.full.pdf+html?sid=bb7db2b1-58e4-41b5-b1de-40116c708e99 American Clinical Neurophysiology Society (ACNS). Guidelines and Consensus Statements. Accessed at: https://www.acns.org/practice/guidelines American Clinical Neurophysiology Society (ACNS). Guideline Twelve: Guidelines for Long-Term Monitoring for Epilepsy. 2008. Accessed at: https://www.acns.org/pdf/guidelines/Guideline-12.pdf Asano E et al. The Diagnostic value of Initial Video-EEG Monitoring in Children—Review of 1000 cases. Epilepsy Res. 2005 Aug-Sep;66(1-3):129-35. Bagary M, et al. Epilepsy, antiepileptic drugs and suicidality. Curr Opin Neurol. 2011;24(2):177-82. Baheti NN, Radhakrishnan A, Radhakrishnan K. A critical appraisal on the utility of long-term video-EEG monitoring in older adults. Epilepsy Res. 2011 Nov;97(1-2):12-9. Epub 2011 Jul 23. Benbadis SR, and LaFrance Jr WC. Clinical features and role of EEG-video monitoring. In: Gates and Rowan's Nonepileptic Seizures. 3rd ed. Cambridge, NY: Cambridge University Press; 2010:38-50. Benbadis SR, et al. Epilepsy surgery, delays and referral patterns-are all your epilepsy patients controlled?. Seizure. 2003;12(3):167-70. Berg AT, et al. Neuroimaging in children with newly diagnosed epilepsy: A community-based study. Pediatrics. 2000;106(3):527-32. Boon P. et al. Interictal and Ictal Video EEG Monitoring. Acta Neurol Belg. 1999 Dec;99(4):247-55. Cascino G. Clinical Indications and Diagnostic Yield of Video-Electroencephalographic Monitoring in Patients with Seizures and Spells. Mayo Clinic Proceedings. 2002 Oct, 77(10). Centers for Medicare & Medicaid Services (CMS). Welcome to the Medicare Coverage Database. Accessed at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

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https://www.aan.com/

http://www.neurology.org/content/60/2/166.full.pdf+html?sid=bb7db2b1-58e4-41b5-b1de-40116c708e99%20

http://www.neurology.org/content/60/2/166.full.pdf+html?sid=bb7db2b1-58e4-41b5-b1de-40116c708e99%20

https://www.acns.org/practice/guidelines

https://www.acns.org/pdf/guidelines/Guideline-12.pdf

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Claassen J, et al. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med. 2013;39(8):1337-51. Dash D, Hernandez-Ronquillo L et al. Ambulatory EEG: a cost-effective alternative to inpatient video-EEG in adult patients. Epileptic Disord. 2012 Sep;14(3):290-7.

Devinsky O, Gazzola D, LaFrance WC. Differentiating between non epileptic and epileptic seizures. Nature reviews. Neurology 2011;7(4):210-20. Dobesberger J, et al. Video-EEG monitoring: safety and adverse events in 507 consecutive patients. Epilepsia 2011; 52(3):443-52. Eisenman LN et al. Self-reported Seizure Frequency and Time to First Event in the Seizure Monitoring Unit. Epilepsia 2005 May;46(5):664-8. Fountain NB, Van Ness PC, Swain-Eng R, Tonn S, Bever CT Jr. Quality improvement in neurology: American Academy of Neurology (AAN) epilepsy quality measures: Report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology. Neurology. 2011;76(1):94-99. Ghougassian DF et al. Evaluating the Utility of Inpatient Video-EEG Monitoring. Epilepsia 2004, Sep 45(8):928-932. Goodwin E, Kandler RH, Alix JJ. The value of home video with ambulatory EEG: a prospective service review. Seizure. 2014 Jun. 23 (6):480-2 Guerreiro CA, Montenegro MA, Kobayashi E, Noronha AL, Guerreiro MM, Cendes F. Daytime outpatient versus inpatient video-EEG monitoring for presurgical evaluation in temporal lobe epilepsy. Journal of Clinical Neurophysiology. 2002 Jun;19(3):204-8. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/12226565

Hayes Medical Technology Directory. Video Electroencephalogram (VEEG) for Diagnosis and Management of Epilepsy in Adults. Winifred Hayes, Inc. October 31, 2013. Annual Review September 25, 2015. Hayes Medical Technology Directory. Video Electroencephalography (VEEG) for the Diagnosis and Treatment of Epilepsy in Children. Winifred Hayes, Inc. October 9, 2013. Annual Review August 11, 2015. InterQual® and CareEnhance® Review Manager. 2012 Procedures Adult Criteria. Video Electroencephalographic (EEG) Monitoring. McKesson Corporation.

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InterQual® and CareEnhance® Review Manager. 2014 Procedures Pediatric Criteria. Video Electroencephalographic (EEG) Monitoring. McKesson Corporation. Kanner AM, et al. Depression and epilepsy, pain and psychogenic non-epileptic seizures: clinical and therapeutic perspectives. Epilepsy Behav. 2012 Jun;24(2):169-81 Kwan P, and Brodie MJ. Early identification of refractory epilepsy. N Engl J Med. 2000;342(5):314-9 Labiner DM, et al. Essential services, personnel, and facilities in specialized epilepsy centers--revised 2010 guidelines. Epilepsia. 2010; 51(11):2322-33. Lee YY et al. Long-term video-EEG monitoring for paroxysmal events. Chang Gung Med J. 2009 May-Jun;32(3):305-12. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/19527610 Lobello K et al. Video/EEG monitoring in the Evaluation of Paroxysmal Behavioral Events: Duration, Effectiveness, and Limitations. Epilepsy Behav. 2006 Feb;8(1):261-6. Madan N, and Grant PE. New directions in clinical imaging of cortical dysplasias. Epilepsia. 2009;50 Suppl 9::9-18. Murrow A M. EEG Seizure Monitoring. Oct 19, 2006. Accessed at: http://emedicine.medscape.com/ Nash KB, Bonifacio SL, Glass HC, et al. Video-EEG monitoring in newborns with hypoxic-ischemic encephalopathy treated with hypothermia. Neurology. 2011;76(6):556-562. National Association of Epilepsy Centers. Guidelines for Epilepsy Centers. Accessed at: http://www.naec-epilepsy.org/spec_care/guidelines.htm National Guideline Clearinghouse. Diagnosis and Management of Epilepsy in Adults. A National Clinical Guideline. Accessed at: www.guideline.gov National Guideline Clearinghouse. The Diagnosis and Management of the Epilepsies in Adults and Children in Primary and Secondary Care. Accessed at: www.guideline.gov National Institute for Health and Clinical Excellence (NICE). The epilepsies: The diagnosis and management of the epilepsies in adults and children in primary and secondary care. London, UK: National Institute for Health and Clinical Excellence (NICE); January 2012. National Institute of Neurological Disorders and Stroke (NINDS). Epilepsy information page. Accessed at: http://www.ninds.nih.gov/disorders/epilepsy/epilepsy.htm Park KI, et al. The value of video-EEG monitoring to diagnosis juvenile myoclonic epilepsy. Seizure 2009 Mar;18(2):94-9.


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Pellock JM, Hrachovy R, Shinnar S, Baram TZ, Bettis D, Dlugos DJ, Gaillard WD, Gibson PA, Holmes GL, Nordli DR, O’Dell C, Shields WD, Trevathan E, Wheless JW. Infantile spasms: A U.S. consensus report. Special Report. Wiley Periodicals, Inc. 2010 International League Against Epilepsy. Epilepsia. 51(10):2175-2189.2010. doi: 10.1111/j.1528-1167.2010.02657.x Pichon Riviere A, Augustovski F, Garcia Marti S, et al. Usefulness of video EEG for the assessment of patients with refractory epilepsy. Summary. IRR No. 220. Buenos Aires, Argentina: Institute for Clinical Effectiveness and Health Policy (IECS); 2011. Pillai JA, Haut SR. Patients with epilepsy and psychogenic non-epileptic seizures: an inpatient video-EEG monitoring study. Seizure. 2012 Jan;21(1):24-7. Epub 2011 Sep 25. Placantonakis DG, Shariff S, Lafaille F, Labar D, Harden C, Hosain S, Kandula P, Schaul N, Kolesnik D, Schwartz TH. Bilateral intracranial electrodes for lateralizing intractable epilepsy: efficacy, risk, and outcome. Neurosurgery. 2010 Feb;66(2):274-83. doi: 10.1227/01.NEU.0000363184.43723.94. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/20087126 Riquet A, et al. Usefulness of video-EEG monitoring in children. Seizure 2011; 20 (1): 18-22. Donat JF. Long-term EEG monitoring for difficult seizure problems. J Child Neurol. 1994;9 Suppl 1:S57-63 Rose AB et al. Occurrence of Seizure Clusters and Status Epilepticus during Inpatient Video EEG Monitoring. Neurology 2003 Mar 25;60(6):975-8. Rossetti AO, Urbano LA, Delodder F, et al. Prognostic value of continuous EEG monitoring during therapeutic hypothermia after cardiac arrest. Crit Care. 2010;14(5):R173.

Roth JL. Status Epilepticus. Practice Essentials. Medscape. Apr 28, 2014. Accessed at: http://emedicine.medscape.com/article/1164462-overview

Sarco DP. Epileptic and Epileptiform Encephalopathies. Medscape. Oct 8, 2013. Accessed at: http://emedicine.medscape.com/article/1179970-overview

Shellhaas RA, et al. The American Clinical Neurophysiology Society’s Guideline on Continuous EEG Monitoring in Neonates. available at http://www.acns.org/pdf/guidelines/Guideline-13.pdf Smith MC, Hoeppner TJ. Epileptic encephalopathy of late childhood: Landau-Kleffner syndrome and the syndrome of continuous spikes and waves during slow-wave sleep. Journal of Clinical Neurophysiology. 2003 Nov-Dec;20(6):462-72. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/14734935







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Sperling MR. Clinical challenges in invasive monitoring in epilepsy surgery. Epilepsia. 1997;38 Suppl 4:S6-12. St. Louis EK. Monitoring Antiepileptic Drugs: A Level-Headed Approach. Curr Neuropharmacol. 2009; 7(2): 115119. Stefan H, Kreiselmeyer G, Kasper B, et al. Objective quantification of seizure frequency and treatment success via long-term outpatient video-EEG monitoring: A feasibility study. Seizure. 2011;20(2):97-100. Sutter R, et al. Continuous video-EEG monitoring increases detection rate of nonconvulsive status epilepticus in the ICU. Epilepsia. 2011;52(3):453-7. Tallawy HN, et al. Role of short-term out patient video electroencephalography in diagnosis of paroxysmal disorders. Epilepsy Res 2010 Feb;88(2-3):179-82. Tsiptsios DI, Howard RS, Koutroumanidis MA. Electroencephalographic assessment of patients with epileptic seizures. Expert Review of Neuro therapeutics 2010; 10(12):1869-86. Vidal-Soto, YE. EEG Video Monitoring. Medscape 2010. Accessed at: http://emedicine.medscape.com/article/1137908-overview#a1. Villanueva V, et al. Usefulness of Video-EEG monitoring in patients with drug-resistant epilepsy. Neurologia. 2011;26(1):6-12. Wang CJ, Jonas, R, Fu CM, Ng, CY, Douglass L. Quality-of-Care Indicators for Infantile Spasms. Journal of Child Neurology. Published online 7 May 2012. DOI: 10.1177/0883073812443590. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/22566712 Waterhouse EJ. Ambulatory EEG. Medscape. November 13, 2015. Accessed at: http://emedicine.medscape.com/article/1139483-overview Wieshmann UC. Clinical application of neuroimaging in epilepsy. J Neurol Neurosurg Psychiatry. 2003;74(4):466-70.

Wirrell E, Kozlik S, Tellez J, et al. Ambulatory electroencephalography (EEG) in children: Diagnostic yield and tolerability. J Child Neurol. 2008;23(6):655-662 Yogarajah M, Powell HW, Heaney D, Smith SJ, Duncan JS, Sisodiya SM. Long term monitoring in refractory epilepsy: the Gowers Unit experience. Journal of Neurology, Neurosurgery, and Psychiatry 2009; 80(3):305-10.

http://emedicine.medscape.com/article/1137908-overview%23a1





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Zhang YC, Bromfield EB, Hurwitz S, Nelson A, Sylvia K, Dworetzky BA. Comparison of outcomes of video/EEG monitoring between patients with epileptic seizures and those with psychogenic non epileptic seizures. Epilepsy and Behavior 2009; 15(3):303-7.

Original Approval Date

Original Effective Date* and Version

Number Policy Owner Approved by

Regulatory Approval: N/A Internal Approval: 05/09/06

06/09/06 Version 1

Medical Policy Manager as Chair of Medical Policy, Criteria, and Technology Assessment Committee (MPCTAC) and member of Quality Improvement Committee (QIC)

Quality and Clinical Management Committee (Q&CMC)

*Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12 *Effective Date for the Well Sense Heath Plan New Hampshire Medicaid Product(s): 01/01/13 *Effective Date for the Senior Care Options Product(s): 01/01/16

Policy Revisions History

Review Date Summary of Revisions

Revision Effective Date and Version

Number

Approved by

05/08/07 Updated clinical criteria, references, template, added coding.

Version 2 05/08/07: MPCTAC 05/24/07: Utilization Management Committee (UMC) 07/12/07: QIC

05/13/08 No changes.

Version 3 05/13/08: MPCTAC 05/20/08: UMC 05/28/08: QIC

05/26/09 No changes to criteria or applicable code list. Updated references.

Version 4 05/26/09: MPCTAC 05/26/09: UMC 06/24/09: QIC

05/01/11 Updated references and the clinical criteria section by changing the criteria from the evaluation and treatment of complex partial and secondary seizures to: Differentiate epileptic events from pseudo-seizures; or to quantify seizure frequency; or to correctly classify seizure type in patients where such characterization is medically necessary to select the most appropriate therapeutic regimen; or to

Version 5 05/18/11: MPCTAC 06/22/11: QIC



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localize the seizure focus in patients with refractory seizures prior to epilepsy surgery; or to establish a diagnosis in neonates or very young children; or in a patient with medically refractory seizure activity despite therapeutic antiepileptic drug levels.

05/01/12 References updated and applicable code list revised to include only video EEG monitoring.


07/30/12 Off cycle review for Well Sense Health Plan. Reformatted Medical Policy Statement and deleted reference to inpatient days.


03/01/13 Review for effective date 07/01/13. Updated References, Summary, and Description of Item or Service sections. Referenced Plan policy, Medically Necessary, policy number OCA: 3.14. Updated language in Applicable Coding section, revised Medical Policy Statement section (formerly titled Clinical Guideline Statement section), and revised and added to Limitations section. Changed name of policy category from “Clinical Coverage Guidelines” to “Medical Policy.”

07/01/13 Version 8

03/20/13: MPCTAC 04/18/13: QIC

08/14/13 and 08/15/13

Off cycle review. Incorporate policy revisions dated 03/01/13 (as specified above) for the Well Sense Health Plan product; these policy revisions were approved by MPCTAC on 03/20/13 and QIC on 04/18/13 for applicable Plan products. Additional review of policy conducted.

Version 9 08/14/13: MPCTAC (electronic vote) 08/15/13: QIC

10/01/13 and 11/08/13

Review for effective date 02/01/14. Revised title, Summary section, Description of Item or Service section, and Clinical Background Information section to include testing in the observation setting and inpatient setting. Revised Medical Policy Statement section to add and categorize criteria by clinical indication, location of care, and testing frequency. Revised limitations. Added limitations for home video EEG monitoring and outpatient video EEG monitoring (in a setting other than

02/01/14 Version 10

11/08/13: MPCTAC (electronic vote after MPCTAC meeting on 10/16/13) 11/21/13: QIC



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observation). Updated References section.

06/25/14 Review for effective date 10/01/14. Revised the Summary section and added a reference to the Well Sense reimbursement policy, Reimbursement Guidelines – Hospital (policy number WS 4.21). Updated Description of Item or Service section and Clinical Background Information section. Added definitions in Definitions section. Revised criteria in the Medical Policy Statement section and Limitations section. Updated references. Defined an adult member as a member age 21 years or older on the date of service.

10/01/14 Version 11

06/30/14: MPCTAC (electronic vote) 07/09/14: QIC

04/01/15 Review for effective date 06/01/15. Removed Commonwealth Care, Commonwealth Choice, and Employer Choice from the list of applicable products because the products are no longer available. Clarified Medical Policy Statement section and Limitations section without changing criteria. Updated references.

06/01/15 Version 12

04/01/15: MPCTAC 05/13/15: QIC

11/25/15 Review for effective date 01/01/16. Updated template with list of applicable products and notes. Revised language in the Applicable Coding section.

01/01/16 Version 13

11/18/15: MPCTAC 11/25/15: MPCTAC (electronic vote) 12/09/15: QIC

04/01/16 Review for effective date 08/01/16. Revised the Clinical Background Information, References, and Reference to Applicable Laws and Regulations sections. Administrative changes made to the Limitations section. Criteria changes made in the Medical Policy Statement section.

08/01/16 Version 14

04/20/16: MPCTAC 05/23/16: QIC

Last Review Date

04/01/16

Next Review Date

04/01/17



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Authorizing Entity

QIC

Other Applicable Policies

Medical Policy – Medically Necessary, policy number OCA 3.14 Reimbursement Guidelines – Hospital, policy number WS 4.21 Reimbursement Guidelines – Inpatient Hospital, policy number 4.110 Reimbursement Guidelines – Observation Services, policy number 4.36

Reference to Applicable Laws and Regulations

78 FR 48164-69. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. August 7, 2013. Accessed at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

Disclaimer Information:+

Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs.

Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members.

The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

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