Clinical Policy Bulletin: Grid Monitoring and Intraoperative Electroencephalography
Intraoperative Electroencephalography (EEG): Aetna considers intraoperative scalp EEG medically necessary for the following indications:
Monitoring cerebral function during carotid artery surgery; or
Monitoring cerebral function during intracranial vascular surgical procedures.
Aetna considers intraoperative EEG experimental and investigational for open-heart surgery and for all other indications because its clinical value has not been established.
Note: The use of intraoperative EEG to monitor brain function for anesthetic drug administration in order to determine depth of anesthesia is considered integral to the anesthesia and not separately reimbursed. In addition, this use of intraoperative EEG is considered experimental and investigational.
Grid Monitoring (Electrocorticography, ECoG): Aetna considers grid monitoring to determine the location of the epileptogenic focus for possible surgical resection medically necessary for members with intractable seizures when any of the following conditions is met:
Seizures arise from functionally important brain areas; or
Surface (scalp) electroencephalogrphy (EEG) recording did not adequately localize the epileptogenic area, or
There is a discordance between electrophysiological localization and that provided by other neurodiagnostic studies suggesting an abnormality in more than one region of the brain.
Aetna considers grid monitoring experimental and investigational for all other indications because its clinical value for these indications has not been established.
Notes: Grid monitoring is considered appropriate only when used by centers that have expertise and experience, especially with younger persons.
For patients with intractable seizures, the best surgical outcome is attained after precise localization of the seizure focus. Scalp electroencephalography (EEG) monitoring may be insufficient and invasive subdural EEG monitoring (by means of subdural grid electrodes) has been used. Subdural electrodes provide coverage of large areas of neocortex and are ideally suited for evaluating children with intractable epilepsy and to functionally map critical cortex.
Multi-contact depth electrodes may be implanted into the brain to record electrical activity from deep or superficial cortical structure. Strips or rectangular grid arrays (subdural electrodes) can be placed under the dura to record activity in this region.
Subdural grid electrodes can be used for recording as well as for stimulating neural tissue to identify the underlying function (e.g., language areas, sensation or motor function). These electrodes remain in place for several days to up to 1 to 2 weeks, as needed to record seizures and map brain. They are then removed and epilepsy surgery performed, if findings are favorable for such surgery. In some patients in whom invasive monitoring fails to locate the seizure focus, re-investigation with invasive subdural electrodes can identify the origin of seizure and allow successful surgical treatment.
Invasive EEG monitoring with subdural grid electrodes is associated with significant complications; however, most of them are transient. Higher complication rates are related to an increased number of electrode contacts, increased length of the monitoring period, placement of burr holes in addition to the craniotomy, and multiple cable exit sites.
An American Academy of Neurology Technology Assessment (Nuwer, et al., 1990) stated that electrocorticography (ECog) from surgically exposed cortex can help to define the optimal limits of a surgical resection, identifying regions of greatest impairment. Regions of attenuated or absent EEG, or those with relatively increased slow activity, decrease in fast activity, or abnormal spike discharges help to define regions of cortex that are impaired or abnormal. When used together with long-term EEG/video monitoring, ECoG can help to define the limits of resection for surgery for epilepsy.
An American Academy of Neurology Technology Assessment (Nuwer, et al., 1990) stated that intraoperative scalp EEG monitoring has long been carried out in an effort to safeguard the brain during carotid endarterectomy. The assessment stated that this technique has been shown to be safe and efficacious for such use and for other similar situations in which cerebral blood flow is at high risk. For this purpose, monitoring should be carried out at least at the anterior and posterior regions over each hemisphere. The AAN technology assessment stated that sixteen channels are preferable to identify occasional embolic complications.
A Medicare National Coverage Determination (CMS, 2006) on EEG monitoring during surgical procedures involving the cerebral vasculature states that EEG monitoring may be covered routinely in carotid endarterectomies and in other neurological procedures where cerebral perfusion could be reduced. Such other procedures might include aneurysm surgery where hypotensive anesthesia is used or other cerebral vascular procedures where cerebral blood flow may be interrupted. A Medicare National Coverage Determination on EEG monitoring for open-heart surgery stated that the value of EEG monitoring during open heart surgery and in the immediate post-operative period is debatable because there are little published data based on well designed studies regarding its clinical effectiveness. The NCD states that the procedure is not frequently used for this indication and does not enjoy widespread acceptance of benefit.
One or two channel intraoperative EEG analysis modules have been used by anesthesiologists to gauge depth of anesthesia, such as the Bi-Spectral device (BIS). Such use of limited channel intraoperative EEG for monitoring depth of anesthesia (and level of consciousness) is considered integral to the anesthesia service and not separately reimbursable. In addition, a one or two channel EEG device does not meet the minimal technical requirements for EEG testing as set forth by the American Clinical Neurophysiology Society.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
Subdural implantation of strip electrodes through one or more burr or trephine hole(s) for long term seizure monitoring
Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring
for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure)
Stereotactic implantation of depth electrodes into the cerebrum for long term seizure monitoring
Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of attendance by a physician or other qualified health care professional
each additional hour of attendance by a physician or other qualified health care professional (List separately in addition to code for primary procedure)
Other CPT codes related to this CPB:
95812 - 95830
95950 - 95967
Special EEG Tests
HCPCS codes covered if selection criteria are met:
Topographic brain mapping
ICD-9 codes covered if selection criteria are met:
345.00 - 345.91
Epilepsy and recurrent seizures
Post traumatic seizures
Intra-operative electroencephalographic (EEG) monitoring of cerebral function [There is no way to code monitoring of brain function for anesthetic drug administration in order to determine depth of anesthesia]:
CPT codes covered if selection criteria are met:
Electroencephalogram (EEG); recording in coma or sleep only)
Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure)
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operation room, per hour (List separately in addition to code for primary procedure)
Electroencephalogram (EEG) during non-intracranial surery (eg, carotid)
HCPCS codes covered if selection criteria are met: :
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)
CPT codes covered if selection criteria are met:
Electrocorticogram at surgery (separate procedure)
ICD-9 codes covered if selection criteria are met: :
345.00 - 345.91
Epilepsy and recurrent seizures
The above policy is based on the following references:
Byer JA, Henzel JH, Dexter JD. Correlation of intraoperative electroencephalography with neurologic deficit after carotid endarterectomy. South Med J. 1979;72(8):956-958.
Jones TH, Chiappa KH, Young RR, et al. EEG monitoring for induced hypotension for surgery of intracranial aneurysms. Stroke. 1979;10(3):292-294.
Brewster DC, O'Hara PJ, Darling RC, Hallett JW Jr. Relationship of intraoperative EEG monitoring and stump pressure measurements during carotid endarterectomy. Circulation. 1980;62(2 Pt 2):I4-I7.
Meneghetti G, Deriu GP, Saia A, et al. Continuous intraoperative EEG monitoring during carotid surgery. Eur Neurol. 1984;23(2):82-88.
Wassmann H, Fischdick G, Jain KK. Cerebral protection during carotid endarterectomy--EEG monitoring as a guide to the use of intraluminal shunts. Acta Neurochir (Wien). 1984;71(1-2):99-108.
Cho I, Smullens SN, Streletz LJ, Fariello RG. The value of intraoperative EEG monitoring during carotid endarterectomy. Ann Neurol. 1986;20(4):508-512.
Nuwer M, Aminoff M, Chatrain G, et al. Assessment: Intraoperative neurophysiology. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 1990;40(11):1644-1646.
Fiol ME, Gates JR, Mireles R, et al. Value of intraoperative EEG changes during corpus callosotomy in predicting surgical results. Epilepsia. 1993;34(1):74-78.
Nuwer MR. Intraoperative electroencephalography. J Clin Neurophysiol. 1993;10(4):437-444.
McKinsey JF, Desai TR, Bassiouny HS, et al. Mechanisms of neurologic deficits and mortality with carotid endarterectomy. Arch Surg. 1996;131(5):526-532.
Adelson PD, Black PM, Madsen JR, et al. Use of grids and strip electrodes to identify a seizure locus in children. Pediatr Neurosurg. 1995;22(4):174-180.
Smith MC, Buelow JM. Epilepsy. Dis Mon. 1996;42(11):729-827.
Lagerlund TD, Cascino GD, Cicora KM, Sharbrough FW. Long-term electroencephalographic monitoring for diagnosis and management of seizures. Mayo Clin Proc. 1996;71(10):1000-1006.
Plestis KA, Loubser P, Mizrahi EM, et al. Continuous electroencephalographic monitoring and selective shunting reduces neurologic morbidity rates in carotid endarterectomy. J Vasc Surg. 1997;25(4):620-628.
Ballotta E, Dagiau G, Saladini M, et al. Results of electroencephalographic monitoring during 369 consecutive carotid artery revascularizations. Eur Neurol. 1997;37(1):43-47.
Sperling MR, Bucurescu G, Kim B. Epilepsy management: Issues in medical and surgical treatment. Postgrad Med. 1997;102(1):102-104, 109-112, 115-118, passim.
Kutsy RL, Farrell DF, Ojemann GA. Ictal patterns of neocortical seizures monitored with intracranial electrodes: Correlation with surgical outcome. Epilepsia. 1999;40(3):257-266.
Siegel AM, Jobst BC, Thadani VM, et al. Medically intractable, localization-related epilepsy with normal MRI: Presurgical evaluation and surgical outcome in 43 patients. Epilepsia. 2001;42(7):883-888.
Otsubo H, Shirasawa A, Chitoku S, et al. Computerized brain-surface voltage topographic mapping for localization of intracranial spikes from electrocorticography. Technical note. J Neurosurg. 2001;94(6):1005-1009.
Simon SL, Telfeian A, Duhaime AC. Complications of invasive monitoring used in intractable pediatric epilepsy. Pediatr Neurosurg. 2003;38(1):47-52.
Onal C, Otsubo H, Araki T, et al. Complications of invasive subdural grid monitoring in children with epilepsy. J Neurosurg. 2003;98(5):1017-1026.
Wiggins GC, Elisevich K, Smith BJ. Morbidity and infection in combined subdural grid and strip electrode investigation for intractable epilepsy. Epilepsy Res. 1999;37(1):73-80.
Siegel AM, Roberts DW, Thadani VM, et al. The role of intracranial electrode reevaluation in epilepsy patients after failed initial invasive monitoring. Epilepsia. 2000;41(5):571-580.
Hamer HM, Morris HH, Mascha EJ, et al. Complications of invasive video-EEG monitoring with subdural grid electrodes. Neurology. 2002;58(1):97-103.
Pinkerton JA Jr. EEG as a criterion for shunt need in carotid endarterectomy. Ann Vasc Surg. 2002;16(6):756-761.
Reuter NP, Charette SD, Sticca RP. Cerebral protection during carotid endarterectomy. Am J Surg. 2004;188(6):772-777.
Johnston JM Jr, Mangano FT, Ojemann JG, et al. Complications of invasive subdural electrode monitoring at St. Louis Children's Hospital, 1994-2005. J Neurosurg. 2006;105(5 Suppl):343-347.
Shah AK, Fuerst D, Sood S, et al. Seizures lead to elevation of intracranial pressure in children undergoing invasive EEG monitoring. Epilepsia. 2007;48(6):1097-1103.
Fountas KN, Smith JR. Subdural electrode-associated complications: A 20-year experience. Stereotact Funct Neurosurg. 2007;85(6):264-272.
Spire WJ, Jobst BC, Thadani VM, et al. Robotic image-guided depth electrode implantation in the evaluation of medically intractable epilepsy. Neurosurg Focus. 2008;25(3):E19.
Van Gompel JJ, Worrell GA, Bell ML, et al. Intracranial electroencephalography with subdural grid electrodes: Techniques, complications, and outcomes. Neurosurgery. 2008;63(3):498-505; discussion 505-506.
Wong CH, Birkett J, Byth K, et al. Risk factors for complications during intracranial electrode recording in presurgical evaluation of drug resistant partial epilepsy. Acta Neurochir (Wien). 2009;151(1):37-50.
Tan TW, Garcia-Toca M, Marcaccio EJ Jr, et al. Predictors of shunt during carotid endarterectomy with routine electroencephalography monitoring. J Vasc Surg. 2009;49(6):1374-1378.
Liubinas SV, Cassidy D, Roten A, et al. Tailored cortical resection following image guided subdural grid implantation for medically refractory epilepsy. J Clin Neurosci. 2009;16(11):1398-1408.
Van Gompel JJ, Meyer FB, Marsh WR, et al. Stereotactic electroencephalography with temporal grid and mesial temporal depth electrode coverage: Does technique of depth electrode placement affect outcome? J Neurosurg. 2010;113(1):32-38.
Ozlen F, Asan Z, Tanriverdi T, et al. Surgical morbidity of invasive monitoring in epilepsy surgery: An experience from a single institution. Turk Neurosurg. 2010;20(3):364-372.
Centers for Medicare and Medicaid Services (CMS). Electroencephalographic monitoring during surgical procedures involving the cerebral vasculature. National Coverage Determination. Medicare Coverage Issues Manual Section 35-37. CMS Manual Section 160.8, Publication No. 100-3. Baltimore, MD: CMS; effective June 19, 2006.
Centers for Medicare and Medicaid Services (CMS). Electroencephalographic (EEG) monitoring during open-heart surgery. National Coverage Determination. CMS Manual Section 160.9, Publication No. 100-3. Baltimore, MD: CMS; 2010.
American Academy of Neurology (AAN). Electroencephalography (EEG) —routine (95812-95827). Coding FAQs. Rochester, MN: AAN; 2011. Available at: http://www.aan.com/go/practice/coding/faqs. Accessed August 17, 2011.
Michaelides C, Nguyen TN, Chiappa KH, et al. Cerebral embolism during elective carotid endarterectomy treated with tissue plasminogen activator: Utility of intraoperative EEG monitoring. Clin Neurol Neurosurg. 2010;112(5):446-449.
Vendrame M, Kaleyias J, Loddenkemper T, et al. Electroencephalogram monitoring during intracranial surgery for moyamoya disease. Pediatr Neurol. 2011;44(6):427-432.
Burkholder DB, Sulc V, Hoffman EM, et al. Interictal scalp electroencephalography and intraoperative electrocorticography in magnetic resonance imaging-negative temporal lobe epilepsy surgery. JAMA Neurol. 2014;71(6):702-709.
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