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1 Disclaimer Description Coverage Determination Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this. Magnetoencephalography (MEG) is a non-invasive neurophysiological technique that measures the magnetic fields associated with electrical activity within the brain. Prior Authorization is required. Logon to Pres Online to submit a request: Presbyterian now uses MCG (formerly Milliman) Criteria #A Due to contractual restrictions, providers may not access the MCG website but may obtain a copy of the criteria from the Prior Authorization staff. C71.1 Malignant neoplasm of brain C71.1 Malignant neoplasm of frontal lobe C71.2 Malignant neoplasm of brain C71.2 Malignant neoplasm of temporal lobe C71.3 Malignant neoplasm of brain C71.3 Malignant neoplasm of parietal lobe C71.4 Malignant neoplasm of brain C71.4 Malignant neoplasm of occipital lobe D D33.2 Benign neoplasm of brain and oth prt central nervous system D33.2 Benign neoplasm of brain, unspecified D33.0 Benign neoplasm of brain, supratentorial D33.1 Benign neoplasm of brain, infratentorial G G Generalized idiopathic epilepsy and epileptic syndromes
2 G Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status D33.1 Benign neoplasm of brain, infratentorial G G Generalized idiopathic epilepsy and epileptic syndromes G Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status partial seizures, not intractable, with status
3 partial seizures, not intractable, without status G Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status G Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status partial seizures, intractable, with status partial seizures, intractable, without status G Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status G Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status G Other generalized epilepsy and epileptic syndromes, not intractable, with status G Other generalized epilepsy and epileptic syndromes, not intractable, without status G Other generalized epilepsy and epileptic syndromes, intractable, with status G Other generalized epilepsy and epileptic syndromes, intractable, without status partial seizures, not intractable, with status partial seizures, not intractable, without status partial seizures, intractable, with status partial seizures, intractable, without status partial seizures, not intractable, with status partial seizures, not intractable, without status G Epileptic seizures related to external causes, not intractable, with status G Epileptic seizures related to external causes, not intractable, without status G Other epilepsy, not intractable, without status G Other epilepsy, not intractable, with status G Lennox-Gastaut syndrome, not intractable, without status G Epileptic spasms, not intractable, with status G Epileptic spasms, not intractable, without status G40.A01 G40.A09 G40.B01 Absence epileptic syndrome, not intractable, with status Absence epileptic syndrome, not intractable, without status Juvenile myoclonic epilepsy, not intractable, with status
4 G40.B09 Juvenile myoclonic epilepsy, not intractable, without status partial seizures, intractable, with status partial seizures, intractable, without status G Other epilepsy, intractable, without status G Other epilepsy, intractable, with status G Lennox-Gastaut syndrome, not intractable, with status G Lennox-Gastaut syndrome, intractable, with status G Lennox-Gastaut syndrome, intractable, without status G Epileptic spasms, intractable, with status G Epileptic spasms, intractable, without status G40.A11 G40.A19 G40.B11 G40.B19 Absence epileptic syndrome, intractable, with status Absence epileptic syndrome, intractable, without status Juvenile myoclonic epilepsy, intractable, with status Juvenile myoclonic epilepsy, intractable, without status G Epilepsy, unspecified, not intractable, with status G Epilepsy, unspecified, not intractable, without status G Epilepsy, unspecified, intractable, with status G Epilepsy, unspecified, intractable, without status G Local-rel (focal) symptc epilepsy w simple partial seizures partial seizures, not intractable, with status partial seizures, not intractable, without status G Epileptic seizures related to external causes, not intractable, with status G Epileptic seizures related to external causes, not intractable, without status G Other epilepsy, not intractable, without status G Other epilepsy, not intractable, with status G Lennox-Gastaut syndrome, not intractable, without status G Epileptic spasms, not intractable, with status G Epileptic spasms, not intractable, without status G40.A01 G40.A09 G40.B01 G40.B09 Absence epileptic syndrome, not intractable, with status Absence epileptic syndrome, not intractable, without status Juvenile myoclonic epilepsy, not intractable, with status Juvenile myoclonic epilepsy, not intractable, without status
5 I67.1 Other cerebrovascular diseases I67.1 Cerebral aneurysm, nonruptured Q28.2 Other congenital malformations of circulatory system Q28.2 Arteriovenous malformation of cerebral vessels Q28.3 Other malformations of cerebral vessels Approval Signatures: Clinical Quality Committee: Medical Director: Pedro Cardona MD Norman White MD Date: May 18, 2017 Publication History: : Original Effective Date, PHP Internal Criteria : Transitioned to, Annual review : Annual review and revision : Annual review : Annual Review : Annual Review : Presbyterian Policy Retired : Presbyterian now uses MCG Criteria A : Annual Review : Annual Review. Accessed MCG A Last update 1/28/16. No change : Annual Review. Accessed MCG A st Edition. Last updated 02/02/17. No changes. This is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The Medical Policies are not a treatment guide and should not be used as such. For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available on the Internet at:
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