Ambulatory Electroencephalography

Number: 0425

Policy

Aetna considers ambulatory electroencephalography (EEG) with or without home video monitoring medically necessary for any of the following conditions, where the member has had a recent (within the past 12 months) neurologic examination and standard EEG studiesFootnotes*:

  1. Classification of seizure type in members who have epilepsy (routine EEG is equivocal) -- only ictal recordings can reliably be used to classify seizure type (or types) which is important in selecting appropriate anti-epileptic drug therapy; or

  2. Diagnosis of a seizure disorder (epilepsy) -- members who have episodes suggestive of epilepsy when history, examination, and routine EEG do not resolve the diagnostic uncertainties (routine EEG should be negative with provocative measures); or

  3. Localization of the epileptogenic region of the brain during pre-surgical evaluation -- to identify appropriate surgical candidates.

Aetna considers ambulatory EEG experimental and investigational for all other indications because of insufficient evidence in the peer-reviewed literature.

Aetna considers the combined use of ambulatory EEG and home-video recording an equally acceptable medically necessary alternative to ambulatory EEG alone.

Footnotes* Requirements for a standard EEG and neurological examination is waived for medically necessary continuous EEG performed in an intensive care unit (ICU).

Duration of Monitoring

The goal of ambulatory EEG is usually achieved within 48 hours.  Ambulatory EEG monitoring for longer than 7 days may be reviewed for medical necessity.

Background

A 24-hour ambulatory electroencephalogram (AEEG) is used to record EEG tracings on a cassette or digital recorder on a continuous outpatient basis.  Electrodes for at least 3 recording channels are secured to the patient's head while a digital or cassette recorder is secured to the patient's waist or to a shoulder harness.  The EEG information is stored for later play back and analysis. A CMS National Coverage Determination (NCD) states that ambulatory EEG should always be preceded by a resting EEG.

The advantage of 24-hour AEEG is its ability to continuously record over a prolonged period both general and localized seizure activity during near-normal activity.  Recent advances in computer technology have improved available capabilities of AEEG monitors.  Lighter weight, smaller, and faster processors with larger digital storage capacity have overcome earlier limitations on EEG recording and analysis.  Commercially available AEEG has evolved during the last 2 decades from 3-channel analog devices to digital machines with reformable montages of up to 32 channels and computer-assisted spike and seizure detection programs.

Ambulatory EEG monitoring may facilitate the differential diagnosis between seizures and syncopal attacks, sleep apnea, cardiac arrhythmias or hysterical episodes.  The test may also allow the investigator to identify the epileptic nature of some episodic periods of disturbed consciousness, mild confusion, or peculiar behavior, where resting EEG is not conclusive.  It may be useful in documenting seizures that are precipitated by naturally occurring cyclic events or environmental stimuli, which are not reproducible in the hospital or clinic setting.  It may also allow an estimate of seizure frequency, which may at times help to evaluate the effectiveness of a drug and determine its appropriate dosage.

Ambulatory monitoring, however, is not necessary to evaluate most seizures, which are usually readily diagnosed by routine EEG studies and history.

Combined Use of Ambulatory EEG and Home-Video Recording

Lawley et al (2015) stated that EEG is an established diagnostic tool with important implications for the clinical management of patients with epilepsy or non-epileptic attack disorder. Different types of long-term EEG recording strategies have been developed over the last decades, including the widespread use of AEEG, which holds great potential in terms of both clinical usefulness and cost-effectiveness.  These investigators presented the results of a systematic review of the scientific literature on the use of AEEG in the diagnosis of epilepsy and non-epileptic attacks in adult patients.  Taken together, these findings confirmed that AEEG is an useful diagnostic tool in patients with equivocal findings on routine EEG studies and influenced management decisions in the majority of studies.  There is evidence that AEEG is also more likely to capture events than sleep-deprived EEG; however, there are currently insufficient data available to compare the diagnostic utility of modern AEEG technology with inpatient video-telemetry.  The authors concluded that further research on the combined use of AEEG and home-video recording is needed.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:

95700 Electroencephalogram (EEG) continuous recording, with video when performed, setup, patient education, and takedown when performed, administered in person by EEG technologist, minimum of 8 channels
95705 Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; unmonitored
95706     with intermittent monitoring and maintenance
95707     with continuous, real-time monitoring and maintenance
95708 Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored
95709     with intermittent monitoring and maintenance
95710     with continuous, real-time monitoring and maintenance
95711 Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; unmonitored
95712     with intermittent monitoring and maintenance
95713     with continuous monitoring and maintenance
95714 Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored
95715     with intermittent monitoring and maintenance
95716     with continuous, real-time monitoring and maintenance
95717 Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; without video
95718     with video (VEEG)
95719 Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period; without video
95720     with video (VEEG)
95721 Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, without video
95722     greater than 36 hours, up to 60 hours of EEG recording, with video (VEEG)
95723     greater than 60 hours, up to 84 hours of EEG recording, without video
95724     greater than 60 hours, up to 84 hours of EEG recording, with video
95725     greater than 84 hours of EEG recording, without video
95726     greater than 84 hours of EEG recording, with video (VEEG)

ICD-10 codes covered if selection criteria are met:

G40.001 - G40.919 Epilepsy and recurrent seizures
P90 Convulsions of newborn
R25.0 - R25.9 Abnormal involuntary movements
R56.01 Complex febrile convulsions
R56.1 Post traumatic seizures
R56.9 Unspecified convulsions

The above policy is based on the following references:

  1. Alix JJ, Kandler RH, Mordekar SR. The value of long term EEG monitoring in children: A comparison of ambulatory EEG and video telemetry. Seizure. 2014;23(8):662-665.
  2. American Medical Association (AMA). Frequently Asked Questions: Medicine: Neurology and Neuromuscular Procedures. CPT Assistant Online. Chicago, IL: AMA; December 2014:pp. 17, 19.
  3. American Medical Association. 24-hour ambulatory EEG monitoring. Diagnostic and Therapeutic Technology Assessment (DATTA). JAMA. 1983;250(24):3340.
  4. Brigo F. An evidence-based approach to proper diagnostic use of the electroencephalogram for suspected seizures. Epilepsy Behav. 2011;21(3):219-222.
  5. Burgess RC. Ambulatory cassette EEG systems. Technology and equipment review. J Clin Neurophysiol. 1991;8(3):351-359.
  6. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Ambulatory EEG Monitoring (160.22). Baltimore, MD: CMS; effective June 12, 1984.  
  7. Chang BS, Ives JR, Schomer DL, Drislane FW. Outpatient EEG monitoring in the presurgical evaluation of patients with refractory temporal lobe epilepsy. J Clin Neurophysiol. 2002;19(2):152-156.
  8. Dash D, Hernandez-Ronquillo L, Moien-Afshari F, Tellez-Zenteno JF. Ambulatory EEG: A cost-effective alternative to inpatient video-EEG in adult patients. Epileptic Disord. 2012;14(3):290-297.
  9. Gilliam F, Kuzniecky R, Faught E. Ambulatory EEG monitoring. J Clin Neurophysiol. 1999;16(2):111-115.
  10. Gonzalez de la Aleja J, Saiz Díaz RA, Martín García H, et al. The role of ambulatory electroencephalogram monitoring: Experience and results in 264 records. Neurologia. 2008;23(9):583-586.
  11. Goodwin E, Kandler RH, Alix JJ. The value of home video with ambulatory EEG: A prospective service review. Seizure. 2014;23(6):480-482.
  12. Hirsch LJ, Haider HA, Moeller J. Video and ambulatory EEG monitoring in the diagnosis of seizures and epilepsy. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2015.
  13. Kandler R, Ponnusamy A, Wragg C. Video ambulatory EEG: A good alternative to inpatient video telemetry? Seizure. 2017;47:66-70.
  14. Kaplan PW, Schachter SC. The role of the neurologist in the management of epilepsy: Guidelines and tools for patient care. The Neurologist. 1996;2:302-314.
  15. 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.
  16. Lawley A, Evans S, Manfredonia F, Cavanna AE. The role of outpatient ambulatory electroencephalography in the diagnosis and management of adults with epilepsy or nonepileptic attack disorder: A systematic literature review. Epilepsy Behav. 2015;53:26-30.
  17. Morris GL. The clinical utility of computer-assisted ambulatory 16 channel EEG. J Med Engineering Technol. 1997;21(2):47-52.
  18. Nagyova R, Horsburgh G, Robertson A, Zuberi SM. The clinical utility of ambulatory EEG in childhood. Seizure. 2019;64:45-49.
  19. National Collaborating Centre for Primary Care. The epilepsies. The diagnosis and management of the epilepsies in adults and children in primary and secondary care. Clinical Guideline 20. London, UK: National Institute for Clinical Excellence (NICE); October 2004.
  20. Olson DM. Success of ambulatory EEG in children. J Clin Neurophysiol. 2001;18(2):158-161.
  21. Ross SD, Estok R,Chopra S, French J. Management of newly diagnosed patients with epilepsy: A systematic review of the literature. Evidence Report/Technology Assessment No. 39. Prepared by MetaWorks, Inc. for the Agency for Healthcare Reseach and Quality (AHRQ). AHRQ Publication No. 01-E038. Rockville, MD: AHRQ; September 2001.
  22. Schomer DL, Ives JR, Schachter SC. The role of ambulatory EEG in the evaluation of patients for epilepsy surgery. J Clin Neurophysiol. 1999;16(2):116-129.
  23. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of epilepsy in adults. SIGN Publication No. 70. Edinburgh, Scotland: SIGN; updated October 2005. 
  24. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of epilepsies in children and young people. SIGN Publication No. 81. Edinburgh, Scotland: SIGN; March 2005.
  25. Seneviratne U, Mohamed A, Cook M, D'Souza W. The utility of ambulatory electroencephalography in routine clinical practice: A critical review. Epilepsy Res. 2013;105(1-2):1-12.
  26. Smith MC, Buelow JM. Epilepsy. Disease-A-Month. 1996;42(11):729-827.
  27. Watemberg N, Tziperman B, Dabby R, et al. Adding video recording increases the diagnostic yield of routine electroencephalograms in children with frequent paroxysmal events. Epilepsia. 2005;46(5):716-719.
  28. Waterhouse E. New horizons in ambulatory electroencephalography. IEEE Eng Med Biol Mag. 2003;22(3):74-80.
  29. 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.
  30. Worrell GA, Lagerlund TD, Buchhalter JR. Role and limitations of routine and ambulatory scalp electroencephalography in diagnosing and managing seizures. Mayo Clin Proc. 2002;77(9):991-998.