1. Aetna considers electroencephalographic (EEG) video monitoring medically necessary for the following indications, where the diagnosis cannot be made by neurological examination, standard EEG studies, and ambulatory cassette EEG monitoring, and non-neurological causes of symptoms (e.g., syncope, cardiac arrhythmias) have been ruled out:

   1. To differentiate epileptic events from psychogenic seizures; or
   2. To establish the first diagnosis of epilepsy; or

   3. To establish the specific type of epilepsy in poorly characterized seizure types where such characterization is medically necessary to select the most appropriate therapeutic regimen.

   In addition, upon individual case review, EEG video monitoring may be considered medically necessary to establish the diagnosis of epilepsy in very young children.

   Note: Once the cause of seizures and specific type of epilepsy has been established, continued video EEG monitoring (e.g., for monitoring response to therapy or titrating medication dosages) is considered not medically necessary. In these cases, response to therapy can be assessed using standard EEG monitoring or ambulatory cassette EEG monitoring.

2. Aetna considers EEG video monitoring medically necessary for identification and localization of a seizure focus in persons with intractable epilepsy who are being considered for surgery. See also CPB 394 - Surgery for Intractable Epilepsy.

3. Aetna considers EEG video monitoring experimental and investigational for all other indications.

Note: The duration of ambulatory EEG monitoring that is considered medically necessary depends on the frequency of the person's symptoms that are being investigated, and generally can be completed in 3 to 5 days. Requests for EEG video monitoring beyond one week (7 days) may be reviewed for continued medical necessity.

Note: The medically necessary level of care a member requires should be addressed individually according to the member's clinical needs. An acute level of care is not considered medically necessary for many persons requiring video EEG monitoring.

See also CPB 221 - Quantitative EEG (Brain Mapping), CPB 289 - Grid Monitoring: Presurgical Evaluation for Patients with Intractable Seizures, and CPB 425 - Ambulatory Electroencephalography.

The Agency for Health Care Policy and Research has stated that information provided by video EEG monitoring has improved patient outcome by permitting accurate diagnoses and modified therapy. Furthermore, the American EEG Society has noted that this procedure is widely regarded as safe and effective for evaluating seizures disorders. The American Epilepsy Society has stated that this technique is the method of choice for the evaluation of intractable and/or undiagnosed seizure disorders. Additionally, many studies have reported the usefulness of this technique, and recommended its use for the diagnosis of psychogenic seizures.

An evidence report prepared for AHRQ (Ross, et al., 2001) concluded that EEG video monitoring was useful for diagnosis of epilepsy if the EEG, CT, and MRI are non-diagnostic, and in diagnosis in very young children, in patients with poorly characterized seizure types, and in those with suspected psychogenic seizures. The report concluded that video EEG has a role subsequent to a new diagnosis if the diagnosis is or becomes uncertain or if surgery is considered. "In summary ... [t]he literature suggests that ambulatory and video EEGs are useful in a first diagnosis if standard EEG, CT, and MRI are non-diagnostic. Video EEGs are also useful in diagnosis in very young children, in patients with poorly characterized seizure types, and in those with suspected psychogenic seizures, especially if episodes are frequent." The report continued: "[T]he evidence, although scant, suggests there is no role for standard EEG in routine monitoring of patients after a new diagnosis of epilepsy. Video EEG has a role subsequent to a new diagnosis if the diagnosis is or becomes uncertain or if surgery is considered" (Ross, et al., 2001).

The role of video and ambulatory EEG is confined to refining or changing an uncertain diagnosis or in preoperative evaluations for seizure surgery (Ross, et al., 2001). When seizures are frequent and features are atypical or uncertain, these EEGs may well contribute information necessary to correct a misdiagnosis. The literature describing these EEGs appears confined to specialists in academic centers.