Policy and Procedure. Title: Video Electroencephalographic (EEG) Monitoring. Division: Medical Management Department: Utilization Management

Transcription

1 Retired Date: Page 1 of POLICY DESCRIPTION: Video Electroencephalographic 2. RESPONSIBLE PARTIES: Medical Management Administration, Utilization Management, Integrated Care Management, Pharmacy, Claim Department, Providers Contracting. 3. DEFINITIONS: 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-operative evaluation of intractable seizures. Video EEG monitoring is generally performed using external electrodes placed on the patient s scalp surface to locate where seizure activity is originating. More invasive monitoring using intracranial electrode placement directly on the surface of the brain may be required. During testing, seizures may be provoked by withdrawing antiepileptic medication, sleep deprivation, or exercise. Normally, Video EEGs are done during an observation admission of up to 48 hours, not as an inpatient admission. EEGs done with internal electrodes are typically done during an inpatient admission. Ambulatory 24-Hour Electroencephalography : 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

2 Retired Date: Page 2 of 10 cerebral function. This category includes the following epilepsy syndromes: early myoclonic encephalopathy, early infantile epileptic 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. 4. POLICY: Prior authorization is required for inpatient Video EEG, Video EEG done anywhere other than a health care facility, and any out of network Video EEG. Prior authorization is not required for Video EEG done during an observation admissions at an In-network facility by an in-network provider. Video Electroencephalographic (Video EEG) monitoring (on an outpatient basis or in an observation unit) is considered medical necessary when the below criteria are met. a) A diagnosis cannot be made by i. a recent neurological examination and standard EEG and ii. non - neurological causes (such as syncope, arrhythmias or severe metabolic derangement) have been ruled out. b) And one or more of the following: i. To establish the diagnosis of first time seizure or ii. To establish the specific type of epilepsy in poorly characterized seizures where the treatment may be based on the type of seizure or iii. To differentiate epileptic events from pseudo seizures or

3 Retired Date: Page 3 of 10 iv. To establish the diagnosis of epilepsy in young (< 3 years old ) children who have an abnormal EEG and clinical symptoms of epilepsy or v. to evaluate the response to treatment in young (< 3 year old ) children who have been diagnosed with epilepsy or vi. To localize the seizure focus in someone who will be undergoing surgery for intractable epilepsy c) An outpatient VEEG can not be done for an emergency indication MetroPlus considers VIDEO EEG monitoring experimental and / or investigational for all other indications (e.g., sleep apnea, diagnosing coma, headache management) 5. LIMITATIONS: a) Authorization for VIDEO EEG will not be approve more than i. Annually for diagnostic purposes ii. Semiannually for purpose of medication adjustment in a member who is not responding to treatment as expected iii. The code is covered only for attended VEEG monitoring iv. Video EEG studies done in the home will not be approved for greater than 48 hours. 6. APPLICABLE PROCEDURE CODES: CPT Description 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 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended 7. 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):

4 Retired Date: Page 4 of 10 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 Current as of May 6, Accessed at: or 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, Accessed at: and c708e99 American Clinical Neurophysiology Society (ACNS). Guidelines and Consensus Statements. Accessed at: American Clinical Neurophysiology Society (ACNS). Guideline Twelve: Guidelines for Long-Term Monitoring for Epilepsy Accessed at: Asano E et al. The Diagnostic value of Initial Video-EEG Monitoring in Children Review of 1000 cases. Epilepsy Res Aug-Sep;66(1-3): Bagary M, et al. Epilepsy, antiepileptic drugs and suicidality. Curr Opin Neurol. 2011;24(2): Baheti NN, Radhakrishnan A, Radhakrishnan K. A critical appraisal on the utility of longterm video-eeg monitoring in older adults. Epilepsy Res 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: Benbadis SR, et al. Epilepsy surgery, delays and referral patterns-are all your epilepsy patients controlled?. Seizure. 2003;12(3): Berg AT, et al. Neuroimaging in children with newly diagnosed epilepsy: A communitybased study. Pediatrics. 2000;106(3):

5 Retired Date: Page 5 of 10 Boon P. et al. Interictal and Ictal Video EEG Monitoring. Acta Neurol Belg Dec;99(4): Cascino G. Clinical Indications and Diagnostic Yield of Video- Electroencephalographic Monitoring in Patients with Seizures and Spells. Mayo Clinic Proceedings Oct, 77(10). Centers for Medicare & Medicaid Services (CMS). Welcome to the Medicare Coverage Database. Accessed at: 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): Dash D, Hernandez-Ronquillo L et al. Ambulatory EEG: a cost-effective alternative to inpatient video- EEG in adult patients. Epileptic Disord Sep;14(3): Devinsky O, Gazzola D, LaFrance WC. Differentiating between non epileptic and epileptic seizures. Nature reviews. Neurology 2011;7(4): Dobesberger J, et al. Video-EEG monitoring: safety and adverse events in 507 consecutive patients. Epilepsia 2011; 52(3): Eisenman LN et al. Self-reported Seizure Frequency and Time to First Event in the Seizure Monitoring Unit. Epilepsia 2005 May;46(5): 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): Ghougassian DF et al. Evaluating the Utility of Inpatient Video-EEG Monitoring. Epilepsia 2004, Sep 45(8): Goodwin E, Kandler RH, Alix JJ. The value of home video with ambulatory EEG: a prospective service review. Seizure 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 Jun;19(3): Accessed at:

6 Retired Date: Page 6 of 10 Hayes Medical Technology Directory. Video Electroencephalogram (VIDEO EEG) for Diagnosis and Management of Epilepsy in Adults. Winifred Hayes, Inc. October 31, Annual Review September 25, Hayes Medical Technology Directory. Video Electroencephalography (VIDEO EEG) for the Diagnosis and Treatment of Epilepsy in Children. Winifred Hayes, Inc. October 9, Annual Review August 11, InterQual and CareEnhance Review Manager Procedures Adult Criteria. Video Electroencephalographic. McKesson Corporation. InterQual and CareEnhance Review Manager Procedures Pediatric Criteria. Video Electroencephalographic. McKesson Corporation. Kanner AM, et al. Depression and epilepsy, pain and psychogenic non-epileptic seizures: clinical and therapeutic perspectives. Epilepsy Behav Jun;24(2): 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): Lee YY et al. Long-term video-eeg monitoring for paroxysmal events. Chang Gung Med J May- Jun;32(3): Accessed at: Lobello K et al. Video/EEG monitoring in the Evaluation of Paroxysmal Behavioral Events: Duration, Effectiveness, and Limitations. Epilepsy Behav Feb;8(1): 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, Accessed at: Nash KB, Bonifacio SL, Glass HC, et al. Video-EEG monitoring in newborns with hypoxicischemic encephalopathy treated with hypothermia. Neurology. 2011;76(6): National Association of Epilepsy Centers. Guidelines for Epilepsy Centers. Accessed at:

7 Retired Date: Page 7 of 10 National Guideline Clearinghouse. Diagnosis and Management of Epilepsy in Adults. A National Clinical Guideline. Accessed at: National Guideline Clearinghouse. The Diagnosis and Management of the Epilepsies in Adults and Children in Primary and Secondary Care. Accessed at: 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 National Institute of Neurological Disorders and Stroke (NINDS). Epilepsy information page. Accessed at: Park KI, et al. The value of video-eeg monitoring to diagnosis juvenile myoclonic epilepsy. Seizure 2009 Mar;18(2):94-9. 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 International League Against Epilepsy. Epilepsia. 51(10): doi: /j 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 Buenos Aires, Argentina: Institute for Clinical Effectiveness and Health Policy (IECS); Pillai JA, Haut SR. Patients with epilepsy and psychogenic non-epileptic seizures: an inpatient video-eeg monitoring study. Seizure 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 Feb;66(2): doi: /01.NEU Accessed at: Riquet A, et al. Usefulness of video-eeg monitoring in children. Seizure 2011; 20 (1): Donat JF. Long-term EEG monitoring for difficult seizure problems. J Child Neurol. 1994;9 Suppl 1:S57-63

8 Retired Date: Page 8 of 10 Rose AB et al. Occurrence of Seizure Clusters and Status Epilepticus during Inpatient Video EEG Monitoring. Neurology 2003 Mar 25;60(6): 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, Accessed at: Sarco DP. Epileptic and Epileptiform Encephalopathies. Medscape. Oct 8, Accessed at: Shellhaas RA, et al. The American Clinical Neurophysiology Society s Guideline on Continuous EEG Monitoring in Neonates. available at 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 Nov-Dec;20(6): Accessed at: 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): 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): Sutter R, et al. Continuous video-eeg monitoring increases detection rate of nonconvulsive status epilepticus in the ICU. Epilepsia. 2011;52(3): Tallawy HN, et al. Role of short-term out patient video electroencephalography in diagnosis of paroxysmal disorders. Epilepsy Res 2010 Feb;88(2-3): Tsiptsios DI, Howard RS, Koutroumanidis MA. Electroencephalographic assessment of patients with epileptic seizures. Expert Review of Neuro therapeutics 2010; 10(12):

9 Retired Date: Page 9 of 10 Vidal-Soto, YE. EEG Video Monitoring. Medscape Accessed at: 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 DOI: / Accessed at: Waterhouse EJ. Ambulatory EEG. Medscape. November 13, Accessed at: Wieshmann UC. Clinical application of neuroimaging in epilepsy. J Neurol Neurosurg Psychiatry. 2003;74(4): Wirrell E, Kozlik S, Tellez J, et al. Ambulatory electroencephalography (EEG) in children: Diagnostic yield and tolerability. J Child Neurol. 2008;23(6): 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): 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): REVISION LOG: REVISIONS DATE Creation date FIDA Removed from LOB 2/1/19 Approved: Date: Approved: Date: Sosler Bruce, MD Clinical Medical Director Talya Schwartz, MD Chief Medical Officer

10 Retired Date: Page 10 of 10 Medical Guideline Disclaimer: Property of Metro Plus Health Plan. All rights reserved. The treating physician or primary care provider must submit MetroPlus Health Plan clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, Metroplus Health Plan will not be able to properly review the request for prior authorization. The clinical review criteria expressed in this policy reflects how MetroPlus Health Plan determines whether certain services or supplies are medically necessary. MetroPlus Health Plan established the clinical review criteria based upon a review of currently available clinical information(including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). MetroPlus Health Plan expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered andor paid for by MetroPlus Health Plan, as some programs exclude coverage for services or supplies that MetroPlus Health Plan considers medically necessary. If there is a discrepancy between this guidelines and a member s benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and website links are accurate at time of publication. MetroPlus Health Plan has adopted the herein policy in providing management, administrative and other services to our members, related to health benefit plans offered by our organization.