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: https://ds.phs.org/preslogin/index.jsp Presbyterian now uses MCG (formerly Milliman) Criteria #A-0481. 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 D33.0 - 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 G40.309 - G40.911 Generalized idiopathic epilepsy and epileptic syndromes
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status D33.1 Benign neoplasm of brain, infratentorial G40.309 - G40.911 Generalized idiopathic epilepsy and epileptic syndromes G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status partial seizures, not intractable, with status
partial seizures, not intractable, without status G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status G40.009 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 G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status G40.419 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 G40.501 Epileptic seizures related to external causes, not intractable, with status G40.509 Epileptic seizures related to external causes, not intractable, without status G40.802 Other epilepsy, not intractable, without status G40.801 Other epilepsy, not intractable, with status G40.812 Lennox-Gastaut syndrome, not intractable, without status G40.821 Epileptic spasms, not intractable, with status G40.822 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
G40.B09 Juvenile myoclonic epilepsy, not intractable, without status partial seizures, intractable, with status partial seizures, intractable, without status G40.804 Other epilepsy, intractable, without status G40.803 Other epilepsy, intractable, with status G40.811 Lennox-Gastaut syndrome, not intractable, with status G40.813 Lennox-Gastaut syndrome, intractable, with status G40.814 Lennox-Gastaut syndrome, intractable, without status G40.823 Epileptic spasms, intractable, with status G40.824 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 G40.901 Epilepsy, unspecified, not intractable, with status G40.909 Epilepsy, unspecified, not intractable, without status G40.911 Epilepsy, unspecified, intractable, with status G40.919 Epilepsy, unspecified, intractable, without status G40.101 Local-rel (focal) symptc epilepsy w simple partial seizures partial seizures, not intractable, with status partial seizures, not intractable, without status G40.501 Epileptic seizures related to external causes, not intractable, with status G40.509 Epileptic seizures related to external causes, not intractable, without status G40.802 Other epilepsy, not intractable, without status G40.801 Other epilepsy, not intractable, with status G40.812 Lennox-Gastaut syndrome, not intractable, without status G40.821 Epileptic spasms, not intractable, with status G40.822 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
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: 07-25-07: Original Effective Date, PHP Internal Criteria 07-23-08: Transitioned to, Annual review 09-23-09: Annual review and revision 09-22-10: Annual review 11-30-11: Annual Review 01-30-13: Annual Review 01-29-14: Presbyterian Policy Retired 01-29-14: Presbyterian now uses MCG Criteria A-0481 03-25-15: Annual Review 05-25-16: Annual Review. Accessed MCG A-0481. Last update 1/28/16. No change. 05-18-17: Annual Review. Accessed MCG A-0481 21 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: http://www.phs.org/phs/healthplans/providers/healthservices/medical/index.htm.