1. Aetna considers electroencephalographic (EEG) video monitoring medically necessary for the following indications, where the diagnosis can not be made by neurological examination, standard EEG studies, and ambulatory 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 a seizure disorder; 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 with clinical symptoms consistent with epilepsy, and abnormal routine EEG consistent with epilepsy.

   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 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 0394 - Epilepsy Surgery.

3. Aetna considers EEG video monitoring experimental and investigational for all other indications (e.g., assessment of the effectiveness of drug treatment in epilepsies, and prognosis of (i) cardiac arrest treated with hypothermia, and (ii) newborns with hypoxic-ischemic encephalopathy treated with hypothermia; not an all inclusive list) because its efefctiveness for these indications has not been established.

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 0221 - Quantitative EEG (Brain Mapping), CPB 0289 - Grid Monitoring: Presurgical Evaluation for Persons with Intractable Seizures, and CPB 0425 - Ambulatory Electroencephalography.

The Agency for Health Care Policy and Research has stated that information provided by video electroencephalographic (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.

An assessment of EEG video monitoring by the Institute for Clinical Effectiveness and Health Policy (Pichon Riviere, et al., 2011) concluded: "In patients with refractory epilepsy who have previously been studied using the standard diagnostic tests, telemetry video electroencephalography (V-EEG) seems to be an adequate diagnostic test to: differentiate a crisis from a pseudocrisis, characterize the different types of crises and localize the epileptic area. Continuous video-EEG monitoring is not considered medically necessary to monitor the antiepileptic drug response or drug titration."

Stefan et al (2011) stated that a reliable method for the estimation of seizure frequency and severity is of value in assessing the effectiveness of drug treatment in epilepsies.  These quantities are usually deduced from subjective patient reports, which may cause considerable problems due to insufficient or false descriptions of seizures and their frequency.  In a feasibility study, these researchers presented data from 2 difficult-to-treat patients with intractable epilepsy.  Patient 1 has had an unknown number of complex partial (CP) seizures.  A prolonged outpatient video-EEG monitoring over 160-hr and 137-hr (over an interval of 3 months) was performed with an automated seizure detection method.  Patient 2 suffered exclusively from nocturnal seizures originating from the frontal lobe.  In this case, an objective quantification of the effectiveness of drug treatment over a time period of 22 weeks was established.  For the reliable quantification of seizures, a prolonged outpatient video/video-EEG monitoring was appended after a short-term inpatient monitoring period.  Patient 1: The seizure detection algorithm was capable of detecting 10 out of 11 seizures.  The number of false-positive events was less than 0.03/hr.  It was clearly demonstrated that the patient showed more seizures than originally reported.  Patient 2: The add-on medication of lacosamide led to a significant reduction in seizure frequency and to a marked decrease in the mean duration of seizures.  The severity of seizures was reduced from numerous hyper-motoric seizures to few mild, head-turning seizures.  The authors concluded that outpatient monitoring may be helpful to guide treatment for severe epilepsies and offers the possibility to more reliably quantify the effectiveness of treatment in the long-term, even over several months.  The findings of this feasibility study need to be validated by well-designed studies.

Therapeutic hypothermia (TH) is becoming standard of care in newborns with hypoxic-ischemic encephalopathy (HIE).  The prognostic value of the EEG and the incidence of seizures during TH are uncertain.  Nash and colleagues (2011) described evolution of EEG background and incidence of seizures during TH, and identified EEG patterns predictive for MRI brain injury.  A total of 41 newborns with HIE who underwent TH were included in this study.  Continuous video-EEG was performed during hypothermia and re-warming.  EEG background and seizures were reported in a standardized manner.  Newborns underwent MRI after re-warming.  Sensitivity and specificity of EEG background for moderate-to-severe MRI brain injury was assessed at 6-hr intervals during TH and re-warming.  EEG background improved in 49 %, remained the same in 38 %, and worsened in 13 %.  A normal EEG had a specificity of 100 % upon initiation of monitoring and 93 % at later time points.  Burst suppression and extremely low voltage patterns held the greatest prognostic value only after 24 hrs of monitoring, with a specificity of 81 % at the beginning of cooling and 100 % at later time points.  A discontinuous pattern was not associated with adverse outcome in most patients (73 %).  Electrographic seizures occurred in 34 % (14/41), and 10 % (4/41) developed status epilepticus.  Seizures had a clinical correlate in 57 % (8/14) and were subclinical in 43 % (6/14).  The authors concluded that continuous video-EEG monitoring in newborns with HIE undergoing TH provides prognostic information about early MRI outcome and accurately identifies electrographic seizures, nearly 50 % of which are subclinical.  The findings of this small study need to be validated by well-designed studies.

Rosetti et al (2010) examined if continuous EEG (cEEG) may predict outcome of patients with coma after cardiac arrest (CA), particularly in the setting of TH.  From April 2009 to April 2010, these researchers prospectively studied 34 consecutive comatose patients treated with TH after CA who were monitored with cEEG, initiated during hypothermia and maintained after rewarming.  EEG background reactivity to painful stimulation was tested.  They analyzed the association between cEEG findings and neurologic outcome, assessed at 2 months with the Glasgow-Pittsburgh Cerebral Performance Categories (CPC).  Continuous EEG recording was started 12 +/- 6 hours after CA and lasted 30 +/- 11 hours.  Non-reactive cEEG background (12 of 15 (75 %) among non-survivors versus none of 19 (0) survivors; p < 0.001) and prolonged discontinuous "burst-suppression" activity (11 of 15 (73 %) versus none of 19; p < 0.001) were significantly associated with mortality.  EEG seizures with absent background reactivity also differed significantly (7 of 15 (47 %) versus none of 12 (0); p = 0.001).  In patients with non-reactive background or seizures/epileptiform discharges on cEEG, no improvement was seen after TH.  Non-reactive cEEG background during TH had a positive predictive value of 100 % (95 % confidence interval (CI): 74 to 100 %) and a false-positive rate of 0 (95 % CI: 0 to 18 %) for mortality.  All survivors had cEEG background reactivity, and the majority of them (14 of 19 (74 %)) had a favorable outcome (CPC 1 or 2).  The authors concluded that cEEG monitoring showing a non-reactive or discontinuous background during TH is strongly associated with unfavorable outcome in patients with coma after CA.  Moreover, they stated that these data warrant larger studies to confirm the value of cEEG monitoring in predicting prognosis after CA and TH.

The National Institute for Health and Clinical Excellence’s clinical guideline on “The epilepsies: The diagnosis and management of the epilepsies in adults and children in primary and secondary care” (NICE, 2012) stated that  “Long-term video or ambulatory EEG may be used in the assessment of children, young people and adults who present diagnostic difficulties after clinical assessment and standard EEG”.