National Medical Policy

National Medical Policy Subject: Video EEG Policy Number: NMP78 Effective Date*: November 2003 Updated: August 2015 This National Medical Poli...
Author: Aron Hensley
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National Medical Policy Subject:

Video EEG

Policy Number:


Effective Date*:

November 2003


August 2015

This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use X

Source National Coverage Determination (NCD)

Reference/Website Link

Ambulatory EEG Monitoring (160.22): Telephone Transmission of EEG (160.21):


National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* Other


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Instructions  Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions.  Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under “Reference/Website” and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage Video EEG Aug 15


determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2)

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If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance.

Current Policy Statement Health Net Inc. considers inpatient video-EEG monitoring medically necessary in any of the following circumstances: 1. Definitive diagnosis cannot be made despite a thorough neurological examination, a negative EEG using provocative measures during the test (such as hyperventilation, sleep deprivation and intermittent photic stimulation) to induce epileptic activity, and negative ambulatory cassette monitoring; 2. A patient has medically refractory seizure activity despite therapeutic drug levels of anti-epileptic drugs; 3. Precise classification of seizure-type and localization of seizure foci is needed in order to provide surgical intervention for intractable epilepsy; 4. To quantify seizure frequency; 5. Seizure monitoring of a child is needed to develop or modify treatment, or to establish the diagnosis of epilepsy in young children with clinical symptoms consistent with epilepsy, but who present with diagnostic difficulties after clinical assessment and standard EEG. Note: The duration of ambulatory EEG monitoring depends on the frequency of the person's symptoms and generally can be completed in 72 hours. EEG video monitoring beyond one week (7 days) may be reviewed for continued medical necessity. Health Net Inc. considers video-EEG monitoring for all other indications, including but not limited to, determining future seizure risk and driving fitness, not medically necessary due to a lack of evidence in the peer review literature demonstrating the role of VEM for this indication.

Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive.

On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. Please note that these may not be the final versions of the codes and

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that will not be accepted for billing or payment purposes until the October 1, 2015 implementation date.

ICD-9 Codes 345.00 345.10 345.11 345.2 345.3 345.40 345.41 345.50 345.51 345.60 345.61 345.70 345.71 345.90 345.91 779.0

Generalized nonconvulsive epilepsy, without mention of intractable epilepsy Generalized convulsive epilepsy Generalized convulsive epilepsy, with intractable epilepsy Petit mal status Grand mal status Partial epilepsy with impairment of consciousness, without mention of intractable epilepsy Partial epilepsy with impairment of consciousness, with intractable epilepsy Partial epilepsy without mention of impairment of consciousness, without mention of intractable epilepsy Partial epilepsy without mention of impairment of consciousness, with intractable epilepsy Infantile spasms, without mention of intractable epilepsy Infantile spasms, with mention of intractable epilepsy Epilepsia partialis continua, without mention of intractable epilepsy Epilepsia partialis continua, with mention of intractable epilepsy Epilespy, unspecified, without mention of intractable epilepsy Epilespy, unspecified, with mention of intractable epilepsy Convulsions in the newborn

ICD-10 Codes G40.001G47.9 P90

Episodic and paroxysmal disorders Convulsions of newborn

CPT Codes 95951


Monitoring for localization of cerebral seizure focus be cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (e.g., for presurgical localization), each 24 hours


Scientific Rationale – Update September 2013 Video electroencephalography (EEG) monitoring is the synchronous recording and display of EEG patterns and video-recorded clinical behavior. Short recordings of several hours can be performed as an outpatient in an EEG laboratory, while longer recordings of 24 hours or more are generally done in a hospital inpatient setting. Wilfong et al. (2012, UpTodate) The EEG should be obtained as soon as possible after a seizure, particularly if an initial EEG was normal. In most patients, the incidence of epileptiform discharges is highest in the first 24 hours after a seizure. In some children, however, the EEG immediately after a seizure will be normal or will show nonspecific background abnormalities (postictal slowing) but no epileptiform activity. If the diagnosis is still in question after the initial EEG, a repeat tracing

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should be done. Attempts should be made to obtain the repeat EEG at a time when the child is most likely to have a seizure. As an example, the EEG should be done in the morning if seizures are occurring primarily in the morning upon awakening, as often occurs in juvenile myoclonic epilepsy. If the seizures are nocturnal, as often occurs in frontal lobe and benign rolandic epilepsy, an all-night sleep recording in the laboratory or an ambulatory EEG should be considered. More than three repeat EEGs adds little further information. Up to 30 to 50 percent of children with epilepsy will be "EEG-negative." In patients with serial negative EEGs and an undiagnosed paroxysmal disorder, inpatient video-EEG or ambulatory EEG recording can be helpful. The National Institute of Clinical Excellence (NICE, 2012) guideline on 'The epilepsies: The diagnosis and management of the epilepsies in adults and children in primary and secondary care,' which stated the following: "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". "The expertise of multidisciplinary teams involved in managing complex epilepsy should include psychology, psychiatry, social work, occupational therapy, counselling, neuroradiology, clinical nurse specialists, neurophysiology, neurology, neurosurgery and neuroanaesthesia. Teams should have MRI and video telemetry facilities available to them". Per NICE:    

Child will be used to describe a child aged from 1 month to 11 years old; Young person will be used to describe those between the ages of 12 and 17; Adult will be used to describe those who are 18 or over; and Older people will be used to describe those who are 65 or over based on the evidence that was reviewed.

All children, young people and adults with epilepsy should have a regular structured review. In children and young people, this review should be carried out at least yearly (but may be between 3 and 12 months by arrangement) by a specialist. In adults, this review should be carried out at least yearly by either a generalist or specialist, depending on how well the epilepsy is controlled and/or the presence of specific lifestyle issues.

At the review, children, young people and adults should have access to: written and visual information; counselling services; information about voluntary organisations; epilepsy specialist nurses; timely and appropriate investigations; referral to tertiary services, including surgery if appropriate.

If seizures are not controlled and/or there is diagnostic uncertainty or treatment failure, individuals should be referred to tertiary services soon for further assessment.

If a diagnosis still can’t be made, the individual may be offered an ‘ambulatory EEG’ or an EEG combined with video recording. An ambulatory EEG uses small electrodes to measure your brain activity over several hours, days or weeks while you continue with your daily life. In a video EEG, the individual will be

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monitored in hospital for several days. If a seizure does occur it is recorded on video and used along with the EEG to help make a diagnosis. There is a Clinical Trial on ' Continuous Video- EEG Monitoring in the Acute Phase in Patients With a Cerebrovascular Attack- Randomisation of a Subpopulation Regarding Treatment Strategy (Video-EEG)' that is not yet open for participant recruitment. The Identifier is NCT01862952 and it was last updated on May 22, 2013. Stroke is a major cause of epilepsy. The pathophysiological mechanisms of poststroke epilepsy are not known. Subclinical epileptiform discharges could contribute to the neuronal damage and influence functional outcome. Electroencefalography (EEG) is the golden standard to detect interictal, ictal and subclinical epileptic brain activity. Patients admitted to the stroke unit with an ischemic or hemorrhagic cerebrovascular attack will undergo a 24 hours video-EEG monitoring to detect epileptiform discharges. Clinical and paraclinical (imaging, serum markers of neuronal damage) parameters will be analysed together with the EEG results. The EEG results will be correlated with the occurence of epileptic seizures and functional outcome and mortality in the acute phase and in the long-term. When subclinical epileptic discharges are found on the EEG, patients will be asked to participate in a second part of the study where they will be randomised into a treatment (with an anti-epileptic drug) versus no-treatment group for a period of 6 months. Outcome parameters will be the occurrence of epileptic seizures, mortality and functional outcome. Our main hypothesis is that the occurrence of subclinical epileptiform discharges during the acute phase following stroke influences functional outcome. The estimated primary completion date is June 2016. Gandelman-Marton et al. (2012) The interictal epileptiform discharge (IED) yield of long-term video-EEG (LTVEEG) monitoring is increased compared to a single outpatient EEG, but was not studied specifically in frontal lobe epilepsy. Since IED recording can influence the length of monitoring when seizures are not recorded during LTVEEG, the authors aimed to assess the IED yield of LTVEEG recording in patients with frontal seizures. The authors retrospectively reviewed the medical records of 20 patients with frontal seizures during non-invasive LTVEEG, between 2003 and 2008 and compared them with the results of out-patient EEG. The study group included 11 (55%) men and 9 women aged 15-82 years (mean: 27 years). LTVEEG duration ranged between 4 and 29 days (mean: 14 days). IEDs were detected by each of the tests in eight (40%) patients. The authors conclude that non-invasive LTVEEG and out-patient EEG have a similar diagnostic yield for IEDs in patients with frontal seizures. Therefore, seizures remain the most relevant clinical outcome of LTVEEG. Seneviratne et al. (2012) Outpatient short-term video-electroencephalographic monitoring (OVEM) is recognized as a useful tool in the diagnosis of epilepsy and other paroxysmal disorders. The aim of this retrospective study was to determine the diagnostic yield of OVEM. The authors analyzed 175 OVEM records of adults (111 females and 64 males) referred over a period of 5 years. The mean length of recording was 3.8. h. The highest yield was found in psychogenic nonepileptic seizures (PNES) (37.1%), followed by interictal epileptiform discharges (17.2%), and epileptic seizures (6.9%). The provisional diagnosis was epilepsy in 77.7% and PNES in 22.3% before the test. Outpatient short-term video-electroencephalographic monitoring changed the pre-test diagnosis in 30.9% of patients. Outpatient shortterm video-electroencephalographic monitoring is a useful diagnostic test for PNES. It has a higher yield for PNES than epilepsy.

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Uysal-Soyer et al. (2012) Absence seizures are idiopathic epilepsies characterized by impairment of consciousness and generalized 2.5-4 Hz spike and slow wave discharges. This prospective study was performed to classify and define properties of subgroups of absence epilepsies. We included 31 patients, of whom seven were in the differential diagnosis group. On admission, absence epilepsy provisional diagnosis was considered in 16 patients clinically and in the other 15 patients based on routine EEG findings. Ictal EEGs were recorded by video-EEG monitoring in 23 of the patients (totally 202 ictal recordings). Patients were diagnosed as childhood absence epilepsy (n=8), juvenile absence epilepsy (n=10), juvenile myoclonic epilepsy (n=3), eyelid myoclonia with absences (n=2), and perioral myoclonia with absences (n=1). Neuroimaging, video-EEG monitoring and especially ictal recordings are important for classification of epilepsies in addition to history, physical examination and routine EEG findings. Video-EEG monitoring is required to classify, to make differential diagnosis and to determine the treatment plan and prognosis. Zsuzsa et al. (2013) the authors have processed data from 597 monitoring sessions on 541 patients between June 1, 2001 and 31 May, 2011 based on our database and the detailed summaries of the procedures. 509 patients were under the age of 18. The average length of the sessions was 3.1 days. The authors have observed habitual episodes or episodes in question in 477 (80%) sessions. 241 (40%) sessions were requested with an epilepsy surgery indication, and 74 patients had 84 operations. 356 (60%) were requested with a differential diagnosis indication, and 191 (53%) cases of epilepsy were diagnosed. We most commonly diagnosed symptomatic generalized epilepsy (57 cases). In 165 sessions the episode in question was not diagnosed as epilepsy. Among the paroxysmal episodes we have identified events of psychogenic origin, movement disorders, sleep disorders and behavioral disorders. Only 3% of the differential diagnosis procedures brought no additional clinical information. The diagnostic efficiency in our 'Video EEG Monitoring' (VEM) laboratory is in accordance with the data found in the literature. Besides epilepsy surgery VEM is recommended if suspected epileptic episodes occur and interictal epileptiform signs are not present or are not in accordance with the symptoms, if there is no explanation for therapy resistance and if paroxysmal episodes of non-epileptic origin are suspected but they cannot be identified based on the anamnesis. VEM is also helpful in diagnosing subtle seizures. The procedure has numerous additional benefits in patient care and in training the parents and hospital staff. Hu et al. (2012) completed a study with the objective to explore the clinical manifestations and electroencephalogram (EEG) features in children with frontal and temporal onset seizures. The method used was video-EEG monitoring that was conducted for 24 h in children with seizure disorders. The results were as follows: There were fewer children with temporal EEG onset seizure (TOS) than with frontal EEG onset seizure (FOS) (p = 0.132). Within the TOS category, PTOS was most frequent, and ATOS was rare (p = 0.001). The mean duration of ATOS was longer than that of TOS and PTOS (p < 0.05). There were no significant differences in seizure frequency and nocturnal attacks between children with TOS and children with FOS. Furthermore, we observed the interictal EEG from three aspects: the background, the location of discharges, and the time of discharges. The frequency of the multi-focal and bilateral discharges of FOS was higher than that of TOS (p < 0.01). The FOS discharged easily and quickly spread to the bilateral hemisphere and formed secondary bilateral synchrony. Focal discharges predominated in TOS, and rarely showed the paroxysm of bilateral synchronous rhythm. Bursts of fast rhythms predominated in the onset of TOS. In contrast, there were a variety of ictal EEG in

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FOS. Finally, it was concluded that in the group of children studied, the clinical and EEG characteristics of TOS were different from those of FOS. Uysal-Soyer et al. (2012) Absence seizures are idiopathic epilepsies characterized by impairment of consciousness and generalized 2.5-4 Hz spike and slow wave discharges. This prospective study was performed to classify and define properties of subgroups of absence epilepsies. We included 31 patients, of whom seven were in the differential diagnosis group. On admission, absence epilepsy provisional diagnosis was considered in 16 patients clinically and in the other 15 patients based on routine EEG findings. Ictal EEGs were recorded by video-EEG monitoring in 23 of the patients (totally 202 ictal recordings). Patients were diagnosed as childhood absence epilepsy (n=8), juvenile absence epilepsy (n=10), juvenile myoclonic epilepsy (n=3), eyelid myoclonia with absences (n=2), and perioral myoclonia with absences (n=1). Neuroimaging, video-EEG monitoring and especially ictal recordings are important for classification of epilepsies in addition to history, physical examination and routine EEG findings. Video-EEG monitoring is required to classify, to make differential diagnosis and to determine the treatment plan and prognosis. Williams et al. (2011) Several studies indicate a higher occurrence than might be expected of seizures in intensive care unit patients, many of which are not clinically apparent. Few of these studies are devoted exclusively to pediatric patients. The purpose of this study is to determine the occurrence of seizures in a cohort of pediatric and neonatal intensive care unit patients. Long-term video electroencephalography (EEG) monitoring studies performed in the pediatric and neonatal intensive care units were reviewed. Age, gender, diagnosis, EEG background, epileptiform activity, time of onset and duration of seizures, presence of electroclinical or electrographic seizures, and survival were collected. One hundred thirty-eight recordings encompassing 122 patients were identified. Thirty-four percent of the sessions identified seizures in the first 24 h (38% of the cohort experienced a seizure at some time during monitoring, which ranged from 1-22 days): 17% captured only electroclinical seizures, 49% were electrographic only, and 34% had both electroclinical and electrographic seizures. Seventy percent of those patients experiencing seizures had their first seizure within the first hour of EEG recording. Younger age and epileptiform activity (including periodic) were associated with the occurrence of seizures. Diagnoses of head trauma and status epilepticus/recent prior seizure were more likely than other at-risk diagnoses to be associated with seizures; cardiac arrest managed with hypothermia was less likely to be associated with seizures. One-fourth of the recordings identified nonepileptic events. Seizures occurred in one-third of critically ill pediatric patients at risk for seizures who underwent video-EEG monitoring, and many of these seizures did not have a clinical correlate. In those at risk for seizures in intensive care units, there should be a low threshold for obtaining long-term monitoring. Ma et al. (2011) To analyze the electroclinical features of children with childhood absence epilepsy (CAE) and discuss the diagnostic criteria for CAE. The videoelectroencephalogram (VEEG) database in our hospital was searched using "absence seizures" and "3-Hz generalized spike and waves (GSW)" as key-words. Other epileptic syndromes with typical absence seizures were carefully excluded. Children meeting the CAE diagnostic criteria of the International League Against Epilepsy (ILAE) in 1989 were further evaluated with the diagnostic criteria proposed by Panayiotopoulos in 2005. Totally 37 children met the 1989 ILAE criteria of CAE. The onset age of absence seizures ranged from 3 to 11 years. All patients had frequent absence seizures (5-60 times per day). Two patients (5.4%) had generalized tonic-

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clonic seizures. Hyperventilation induced absences in all patients. VEEG confirmed that 7 patients (18.9%) had only simple absences, 25 patients (67.6%) had only complex absences, and 5 patients (13.5%) had both simple and complex absences. Ictal EEG showed 3. Hz GSW discharges in all patients. The seizure duration ranged from 3 to 40 s. Four patients (10.8%) had two spikes per wave in ictal EEG. GSW fragments were found in 29 patients (78.4%) during sleep. Interictal polyspikes and waves were present in 17 patients (45.9%). Focal discharges predominantly in the anterior regions, were found in 22 patients (56.8%). Only 7 patients (18.9%) met the diagnostic criteria proposed by Panayiotopoulos in 2005. Mikati et al. (2011) Psychogenic nonepileptic seizures are conversion reactions that are usually suspected clinically based on the characteristics of the spells. The diagnosis can be confirmed by video EEG with capture of an episode to eliminate any residual doubts about their nature, as they can often occur in patients who also have epileptic seizures. Psychogenic seizures are also less likely than epileptic seizures to be associated with increased serum prolactin levels 15-120 min after the event. They are best managed acutely by reassurance about their relatively benign nature and by a supportive attitude. Psychiatric evaluation and follow-up are needed to uncover potential underlying psychopathology, particularly in adolescents and adults, and to establish continued support as psychogenic seizures can persist over long periods of time. Malingering and Munchausen syndrome by proxy are often difficult to diagnose but an approach similar to that for psychogenic seizures, including video-EEG monitoring, is often helpful. Akman et al. (2009) Subclinical seizures (SCSs) are characterized by paroxysmal rhythmic epileptiform discharges that evolve in time and space in the absence of objective clinical manifestation or report of a seizure. The aim of this study was to evaluate the frequency and characteristics of SCSs in children with localizationrelated epilepsy (LRE). The results of video/EEG monitoring were reviewed to identify patients with SCS. We identified 187 children diagnosed with LRE, in 32 of whom SCSs were reported in the EEG recording. SCSs were reported only in the children who had received a diagnosis of either symptomatic or cryptogenic LRE. All children had a history of clinical seizure(s). The ictal onset of SCSs was most frequent from the temporal and frontal lobes. SCSs were lateralized to the left hemispheres in 19, right hemisphere in 8, and both hemispheres independently in 5 children. SCSs were more often reported in young children, and associated with a history of developmental delay, infantile spasms, and frequent seizures. EEG abnormalities included background slowing and lack of normal sleep architecture in addition to the epileptiform activity. Seizure freedom was reported less often in children with SCSs. Six patients seizure free at the time of the admission were found to have SCSs. Subclinical seizures are not uncommon in children with LRE, in particular, with younger age, developmental disability, and medically refractory clinical course. Video/EEG monitoring will be informative in selected children with LRE to assess the seizure frequency more accurately. Akman et al. (2009) The objective of this study was to ascertain the accuracy of clinical reports to determine the seizure frequency in children diagnosed with epilepsy. Methods: We reviewed the clinical record of 78 children (January-May of 2006) admitted to the EEG-video monitoring with epilepsy diagnosis. Clinical reports of parents and the files of EEG-video monitoring were reviewed to determine parents' awareness for seizures. Results: During video-EEG monitoring, 1244 were recorded on 78 children. Seizures were confirmed in 1095 of which 472 were correctly reported (38%) by parents whereas 623 remained under-reported (50%). Parents'

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report thus had a sensitivity of 43%, positive predictive value of 76% to identify seizures. Based on the EEG-video monitoring, seizures were reported accurately in 22 (28%) and under-reported in 38 (49%) children. In the under-reported group, none of the seizures were recognized in 10 (13%), only a portion identified in 28 children. The parents' report describing seizure frequency has limited value for young children (p = 0.01) and children with absence seizures (p = 0.03). However, clinical reports were accurate for the children with developmental delay (p < 0.06) or not being on any anticonvulsant drug (AED) therapy (p = 0.02). Conclusion: Our results indicate that a significant number of seizures remain under-reported by parents of children with epilepsy. The current study underscores that the seizure frequency should be interpreted with caution for young children and children with absence seizures. Video-EEG recording has a complimentary role to the clinical observation for the accurate assessment of seizure frequency in children. Per MD Consult, video recording is very useful in diagnosing epilepsy when inadequate or inaccurate histories are available from eyewitnesses. Surgery is reserved for patients with severe, medically intractable epilepsy. Only patients with a clearly localizable seizure focus (usually mesial temporal sclerosis) are candidates. A battery of tests, including long-term video monitoring and the Wada test (to determine the location of the language center), are required before surgical intervention. In children with extensive hemispheric lesions, total hemispherectomy early in life is the best treatment option, as the procedure not only improves seizure control but also arrests the intellectual deterioration that is associated with the intractable seizure disorder.

Scientific Rationale – Update March 2011 Routine electroencephalography (EEG) is usually sufficient to classify seizure type and initiate treatment in individuals with epilepsy. For those individuals with intractable recurrent seizures and those with an unconfirmed seizure diagnosis, inpatient video electroencephalography (EEG) monitoring is a useful diagnostic tool. Video-EEG monitoring (VEM) is the synchronous recording and display of EEG patterns and video-recorded clinical behavior. Short recordings of several hours can be performed as an outpatient in an EEG laboratory, while longer recordings of 24 hours or more are generally done in a hospital inpatient setting. The longer the duration of the study, the more likely the study is to record a clinical event. In a case series, Friedman and Hirsch (2009) reported of 248 adult patients admitted to the epilepsy monitoring unit, the median time to first diagnostic event, whether epileptic seizure or nonepileptic event, was 2 days; 35 percent of patients required 3 or more days of monitoring, and 7 percent more than 1 week. For individuals with recurrent clinical events, VEM in an epilepsy-monitoring unit may be useful in making a definitive diagnosis. VEM can also help with seizure classification, which impacts the most appropriate selection of an antiepileptic drug (AED). VEM is also useful preoperatively in individuals with pharmacoresistant partial epilepsy for surgical localization. It is generally agreed that a patient with uncontrolled epilepsy who drives is at risk for a motor vehicle accident, however, for many adults, restrictions on driving place severe limitations on their ability to participate in school, employment, and social activities and therefore significantly diminishes independence and quality of life. With the development of effective antiepileptic drugs, and the recognition that many patients with epilepsy were well controlled and therefore at low risk for seizures while driving, laws have been successively revised to relax this total restriction.

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Regulations vary considerably in different states and countries, and there is a lack of consensus even among experts. The seizure free interval is the most practical and widely used measure of a patient's driving risk. Longer seizure free intervals (>6 to 12 months) are associated with reduced risk of seizure-related motor vehicle accident (MVA). Shortening seizure free intervals to three months by some states has not been associated with increased MVAs. A 1994 consensus statement from the American Academy of Neurology (AAN), American Epilepsy Society (AES), and the Epilepsy Foundation of America (EFA) advocated a three month seizure free interval, with allowance for modifiers that may extend or shorten the interval. The AAN, AES, and EFA consensus opinion also outlined other risk factors for MVA in persons with epilepsy:  Noncompliance with medication or medical visits, or lack of credibility  Recent history (three months) of alcohol or drug abuse  Structural brain disease  Uncorrectable brain functional or metabolic disorder  Frequent seizure recurrences after seizure free intervals  Prior crashes caused by seizures The presence of any of these risk factors should lead the clinician to consider extending the seizure free interval requirement for driving, but no specific recommendations for the length of the extension in any of these situations was made. Clinicians have an important role in evaluating patients' ability to drive. Clinicians neither grant nor suspend driving privileges; this is the sole legal prerogative of the state. Nonetheless, physicians should counsel patients regarding the risks associated with driving and epilepsy and the applicable driving laws in their state. The use of prolonged video EEG, rather than routine electroencephalography (EEG), in predicting the risk of future seizures in patients with epilepsy is not well studied. A longer period of monitoring could be more likely to capture either ictal or interictal epileptiform activity. Karmel et al (2010) evaluated the use of 6-hour prolonged VEM versus routine EEG in the assessment of future seizure risk and driving fitness for 34 patients with epilepsy. Data on consecutive patients referred for 6-hour prolonged video EEG monitoring were retrospectively analyzed. Criteria were developed that combined EEG findings and clinical factors to determine each patient's fitness to drive. Seizure relapse outcomes were followed over 2 years. The investigator reported that of 34 patients, 27 were considered safe to drive following prolonged VEM. Five (19%) of these 27 patients had seizure relapses; all had an obvious precipitant(s) identified including sleep deprivation, excessive alcohol, and missed medication doses. Seven of the 34 patients were deemed unsafe to drive. All seven (100%) had seizure relapses, with unprovoked seizures in four patients. The relative risk of seizure in patients deemed unfit to drive was 5.4 (P=0.00015). If only the routine EEG component of the recordings were used with the criteria, the relative risk would have been 3.4 (P=0.037), with nearly double the number of active drivers having seizures. The majority of patients (76%) in this study had idiopathic generalized epilepsy, with a relative seizure risk of 4.0 (P=0.002) for patients deemed unfit to drive in this subgroup. The focal epilepsy group was small (eight patients) and did not quite achieve statistical significance. The investigator concluded six-hour VEM improves the evaluation of driving fitness by better predicting the risk of subsequent seizure relapse for idiopathic generalized epilepsy and possibly focal

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epilepsy. Prolonged monitoring is superior to routine EEG. Ongoing avoidance of seizure-provoking factors remains paramount to driving safety. Boon et al (2009) evaluated the diagnostic efficacy and therapeutic relevance of video-EEG monitoring in an large patient population with long-term follow-up. 400 patients were monitored at an epilepsy monitoring unit. In all patients, the following parameters were retrospectively examined: reason for referral, tentative diagnosis, prescribed antiepileptic drugs (AEDs), seizure frequency, number of admission days, number of recorded seizures, ictal and interictal EEG, clinical and electroencephalographic diagnosis following the monitoring session. During follow-up visits at the clinic, data on different types of treatment and post-monitoring seizure control were prospectively collected. 255/400 (64%) patients were referred for refractory epilepsy. 145/400 (36%) patients were evaluated for attacks of uncertain origin. Mean follow-up, available in 225 patients, was 28 months (range: 6-80 months). Mean duration of a single monitoring session was 4 days (range: 2-7 days). Prolonged interictal EEG was recorded in all patients and ictal EEG in 258 (65%) patients. Following the monitoring session, the diagnosis of epilepsy was confirmed in 217 patients. Pseudoseizures were diagnosed in 31 patients (8%). AEDs were started in 19 patients, stopped in 6 and left unchanged in 110. The type and/or number of AEDs was changed in 111 patients. Sixty patients underwent epilepsy surgery. In 48 surgery patients, follow-up data were available, 29 of whom became seizure-free, and 16 of whom experienced a greater than 90% seizure reduction. Vagus nerve stimulation was performed in 11 patients, 2 became seizure-free, and 7 improved markedly. Of the non-invasively treated patients in whom follow-up was available (n = 135), 70 became seizure-free or experienced a greater than 50% reduction in seizure frequency; 51 patients experienced no change in seizure frequency. Outcome was unrelated to the availability of ictal video-EEG recording. In patients with complex partial seizures, seizure control was significantly improved when a well-defined ictal onset zone could be defined during video-EEG monitoring. The investigators concluded that prolonged interictal EEG monitoring is mandatory in the successful management of patients with refractory epilepsy. Ictal video-EEG monitoring is very helpful but not indispensable, except in patients enrolled for presurgical evaluation or suspected of having pseudoseizures. None of the individuals in this trial were referred for video EEG to assess future seizure risk and driving fitness. According to Ghougassian et al (2004), inpatient VEM is widely used for the diagnosis, seizure classification, and presurgical evaluation of patients with seizure disorders. At this time, VEM for determining future seizure risk and driving fitness is considered investigational and therefore not medically necessary, due to a lack of evidence in the peer review literature demonstrating the role of VEM for this indication

Scientific Rationale – Update January 2011 Villanueva et al (2010) evaluated the characteristics of patients on whom long-term Video-EEG monitoring is performed in a specialist center and to assess its suitability to study refractory epilepsy patients. A prospective analysis and study of Video-EEG monitoring was performed in a series of 100 refractory epilepsy patients from a single center. The analysis included demographic data, the time until the first seizure, the methods used to provoke seizures, and the outcome (usefulness, change in the management, pharmacological and surgical improvement). A subgroup analysis based on diagnosis was performed. The study was performed mainly on

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young people (mean 34.4 years) and the first seizure appeared in a mean of 30 hours, requiring most of the patients to withdraw the medication. Nevertheless, there were no cases of status epilepticus. The usefulness of the test was high in all the groups. The management was changed in 65% of the patients with pharmacological and surgical improvement. The investigators concluded long-term Video-EEG monitoring is a suitable test to study refractory epilepsy patients. In a prospective study, Lee et al (2009) investigated the general clinical application of long term video-electroencephalography monitoring (VEM) in the management of paroxysmal events. The study cohort consisted of patients admitted to the inpatient VEM unit at a single center. Standard 19 channel scalp electroencephalography (EEG), electrocardiography (ECG), and simultaneous video images were recorded continuously for 2 full days. Patient characteristics, and clinical, video-EEG and safety data were obtained and analyzed. The diagnosis and management of paroxysmal events before VEM were compared with those after VEM. Habitual events were recorded in 54.3% of the 129 patients, and VEM had a yield rate of 76% (events recorded or newly recorded interictal discharges) indetermining the nature of the events. Eleven patients had seizure clusters, but there was no status epilepticus or electrode-related injury. After VEM, the diagnostic categories were changed in 41.1% of the patients, and 40.3% had revisions in management. The investigators concluded long term VEM is a safe diagnostic tool providing a high diagnostic yield rate and directing adjustment of management for patients with paroxysmal events. Noe et al (2009) determined the rate of medical complications from long-term videoelectroencephalographic (EEG) monitoring for epilepsy. The medical records of 428 consecutive adult patients with epilepsy who were admitted for diagnostic scalp video-EEG monitoring were reviewed. 149 met inclusion criteria for the study. Seizure number and type as well as timing and presence of seizure-related adverse outcomes were noted. Of the 149 adult patients included in the study, seizure clusters occurred in 35 (23%); 752 seizures were recorded. The mean time to first seizure was 2 days, with a mean length of stay of 5 days. Among these patients, there was 1 episode of status epilepticus, 3 potentially serious electrocardiographic abnormalities, 2 cases of postictal psychosis, and 4 vertebral compression fractures during a generalized convulsion, representing 11% of patients with a recorded generalized tonic-clonic seizure. No deaths, transfers to the intensive care unit, falls, dental injuries, or pulmonary complications were recorded. An adverse event requiring intervention or interfering with normal activity occurred in 21% of these patients. Length of stay was not affected by occurrence of adverse events. The reviewers concluded prolonged video-EEG monitoring is an acceptably safe procedure. Adverse events occur but need not result in substantial morbidity or increase length of hospitalization. Appropriate precautions must be in place to prevent falls and promptly detect and treat seizure clusters, status epilepticus, serious electrocardiographic abnormalities, psychosis, and fractures.

Scientific Rationale - Update October 2007 Per the (NINDS) (National Institute of Neurological Disorder and Stroke (2007), video monitoring is often used in conjunction with EEG to determine the nature of a person's seizures. It also can be used in some cases to rule out other disorders such as cardiac arrhythmia or narcolepsy that may look like epilepsy. The seizures that result from abnormal neuron activity in the brain may be caused by neurological imbalances, or medical conditions (eg., drug or alcohol withdrawal).

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Therefore, seizure type and precipitating causes should be identified to determine the best course of treatment. Activity between seizures is recorded by routine surface electroencephalography (EEG) in approximately 50% of patients; since not all seizure activity is localized to the temporal lobe, which is the most common site of seizure activity, many patients may be misdiagnosed or inadequately treated (National Institutes of Neurological Disorders and Stroke), 2006. Video EEG can be performed on all age groups, including neonates. This technique is especially helpful while treating neonatal seizures. Although antiepileptic drugs may mask signs of seizures, additional seizure activity can occur undetected because of the absence of physical manifestations (de Vries, 2006). Seizure activity may continue even though a surface EEG appears normal. A normal patient may also show unusual brain activity on a surface EEG and be incorrectly diagnosed. Benbadis et al. (2006) Authors have reported through several retrospective studies, the value of adding Video EEG to EEG recording data in confirming the presence or absence of epileptic conditions in infants, children, adolescents, and the elderly. Each of these studies confirmed that Video EEG assisted in obtaining a definitive diagnosis, while avoiding the overuse of antiepileptic medications. Lobello et al. (2006) conducted a retrospective chart review of 199 consecutive patients, in an attempt to determine the number of days that would be needed to conduct Video EEG behavioral event monitoring of adults. The majority of the patients admitted had rapid tapering of their antiepileptic drugs. Patients were subjected to hyperventilation and photic stimulation and told that these stimuli could activate seizures. One hundred and sixty-seven patients did experience an event during admission with the median number of events equaling two. The median number of monitoring days for all patients was three. The authors concluded that the use of outpatient V-EEG may be an informative alternative to inpatient monitoring; as the diagnostic yield of monitoring beyond two–three days may be low. The authors also noted that a limitation within this study was a lack of documentation concerning tapering schedules and the use of placebo was inconsistent between physicians and patients.

Scientific Rationale - Initial According to the AHRQ [Agency for HealthCare Research and Quality] (formerly the AHCPR [Agency for Health Care Policy and Research]), electroencephalographic (EEG) video monitoring is a technique that provides simultaneous documentation of the behavioral and electroencephalographic manifestations of seizures. EEG monitoring, a common diagnostic procedure that records brain wave patterns, has been routinely used in the diagnosis and classification of epilepsy and allied seizure disorders for many years. Investigators and clinicians have reported that EEG video monitoring results in significantly expanded EEG diagnostic capability. The standard or routine EEG examination is performed in a clinician's office or laboratory environment and usually lasts from 20 minutes to 1 hour. When the routine part of the examination has been completed, recording continues while activation procedures such as sleep, sleep deprivation, light stimulation, and hyperventilation are undertaken in an attempt to provoke abnormalities. The electroencephalogram (EEG) is an essential study in the diagnostic evaluation of epileptic seizures. If abnormal, the EEG may substantiate the diagnosis of epileptic seizures and indicate whether a patient may have generalized or partial seizures.

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Obtaining the EEG in the sleep-deprived state and using provocative measures during the test, such as hyperventilation and intermittent photic stimulation, increase the diagnostic yield of the test. In some difficult cases of suspected epilepsy, more precise information may be required for an accurate diagnosis and effective treatment. In these situations, EEG video monitoring is used to help make the differential diagnosis of epileptic versus nonepileptic seizure. For epileptic patients whose seizures remained uncontrolled, this technique can be been used to classify the epileptic seizure for proper diagnosis and treatment. Moreover, EEG video monitoring has been used to establish the diagnosis and focality of an epileptic disorder for surgical intervention. EEG video monitoring can be performed in the outpatient or partial hospitalization setting, epilepsy centers, as well as in the inpatient hospital setting. Video/EEG recordings should only be undertaken after a conventional EEG recording is analyzed and provides equivocal or unclear information for diagnosis. For cases in which the seizures are unwitnessed and clinical presentation is vague, (i.e., psychosomatic or psychiatric etiology suspected) a psychiatric/psychological evaluation may be warranted.

Review History November 18, 2003 October 2005 October 2007 January 2011 March 2011 September 2011 October 2011

August 2012 September 2013

August 2014 August 2015

Medical Advisory Council initial approval Update. No revisions Update. No revisions Update – no revisions Added VEM to determine future seizure risk and driving fitness is considered investigational and therefore not medically necessary. Update. Added revised Medicare Table. No Revisions Changed duration of ambulatory EEG monitoring in Policy Statement to 72 hours, and removed the 3-5 days, to be more consistent with the Ambulatory EEG policy. Update – no revisions Update. Added seizure monitoring of a child is needed to develop or modify treatment, or to establish the diagnosis of epilepsy in young children with clinical symptoms consistent with epilepsy, but who present with diagnostic difficulties after clinical assessment and standard EEG. Updated codes. Update – no revisions. Codes updated. Update – no revisions. Codes updated.

This policy is based on the following evidence-based guidelines: 1. EEG Seizure Monitoring. eMedicine. Accessed October 2005. 2. Health Services /Technology Assessment Text. Electroencephalographic (EEG) Video Monitoring. 3. National Institute of Neurological Disorders and Stroke (NINDS). Seizures and Epilepsy: Hope through research. Updated October 2006. Available at: 4. National Institute for Health and Clinical Excellence (NICE). The epilepsies: The diagnosis and management of the epilepsies in adults and children in primary and

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6. 7. 8. 9.

secondary care. London, UK: National Institute for Health and Clinical Excellence (NICE); January 2012. National Institute for Health and Clinical Excellence (NICE). Quality standard for the epilepsies in children and young people (QS27). February 2013. Available at: National Institute for Health and Clinical Excellence (NICE). (QS26) Quality standard for the epilepsies in adults. February 2013. National Institute for Health and Clinical Excellence (NICE). CMG47: Services for the diagnosis and management of the epilepsies in adults, children and young people. February 28, 2013. Hayes. Search & Summary. Video Electroencephalograph (EEG) Monitoring for Diagnosis of Epilepsy in Children. December 17, 2012. Updated October 9, 2013. Updated September 29, 2014. Hayes. Search & Summary. Video Electroencephalograph (EEG) Monitoring for Diagnosis of Epilepsy in Adults. January 2, 2013. Updated October 31, 2013. Updated September 30, 2014.

References – Update August 2015 1.


Jin B, Zhao Z, Guo Y, et al. Diagnostic yield of inpatient videoelectroencephalographic monitoring: experience from a Chinese comprehensive epilepsy center. Epilepsy Behav. 2014 May;34:77-80. doi: 10.1016/j.yebeh.2014.03.010. Epub 2014 Apr 12. Kumar-Pelayo M, Oller-Cramsie M, Mihu N, et al. Utility of video-EEG monitoring in a tertiary care epilepsy center. Epilepsy Behav. 2013 Sep;28(3):501-3. doi: 10.1016/j.yebeh.2013.06.015. Epub 2013 Jul 26.

References – Update August 2014 1. 2.

Arrington DK, Ng YT, Troester MM, et al. Utility and safety of prolonged videoEEG monitoring in a tertiary pediatric epilepsy monitoring unit. Epilepsy Behav 2013; 27:346. Pati S, Kumaraswamy VM, Deep A, et al. Characteristics of falls in the epilepsy monitoring unit: a retrospective study. Epilepsy Behav 2013; 29:1.

References – Update September 2013 1. 2. 3. 4. 5.

Akman CI, Montenegro MA, Jacob S, et al. Seizure frequency in children with epilepsy: Factors influencing accuracy and parental awareness. Seizure. 18 (7) (pp 524-529), 2009. Akman CI, Montenegro MA, Jacob S, et al. Subclinical seizures in children diagnosed with localization-related epilepsy: Clinical and EEG characteristics. Beniczky SA, Fogarasi A, Neufeld M, et al. Seizure semiology inferred from clinical descriptions and from video recordings. How accurate are they? Epilepsy and Behavior. 24 (2) (pp 213-215), 2012. Blumberg J, Fernandez IS, Vendrame M, et al. Dacrystic seizures: Demographic, semiologic, and etiologic insights from a multicenter study in long-term videoEEG monitoring units. Epilepsia. 53 (10) (pp 1810-1819), 2012. Continuous Video- EEG Monitoring in the Acute Phase in Patients With a Cerebrovascular Attack- Randomisation of a Subpopulation Regarding Treatment Strategy (Video-EEG). Identifier: NCT01862952. May 22, 2013. Available at:

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6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Gandelman-Marton R, Kipervasser S, Neufeld MY. Long-term video-EEG in patients with frontal seizures. Neurological Research. 34 (10) (pp 957-959), 2012. Guldiken B, Baykan B, Sut N, et al. The evaluation of the agreements of different epilepsy classifications in seizures recorded with video EEG monitoring. Journal of Neurological Sciences. 29 (2) (pp 201-211), 2012. Hirsch LJ, Arif H, Moeller J. Video and ambulatory EEG monitoring in the diagnosis of seizures and epilepsy. UpToDate. December 20, 2011. Updated January 2014. Hu Y, Jiang L, Yang Z. Video-EEG monitoring differences in children with frontal and temporal onset seizures. International Journal of Neuroscience. 122(2):92101, 2012 Feb. Kliegman: Nelson Textbook of Pediatrics, 19th ed. 2011 Saunders, An Imprint of Elsevier. Non-REM Partial Arousal Disorders. Ma X, Zhang Y, Yang Z, et al. Childhood absence epilepsy: Elctroclinical features and diagnostic criteria. Brain and Development. 33 (2) (pp 114-119), 2011. Mikati MA, Obeid M. Kliegman: Nelson Textbook of Pediatrics, 19th ed. 2011 Saunders, An Imprint of Elsevier. Chapter 587 – Conditions That Mimic Seizures Noe KH, Grade M, Stonnington CM, et al. Confirming psychogenic nonepileptic seizures with video-EEG: Sex matters. Epilepsy and Behavior. 23 (3) (pp 220223), 2012. Seneviratne U, Rahman Z, Diamond A, et al. The yield and clinical utility of outpatient short-term video-electroencephalographic monitoring: A five-year retrospective study. Epilepsy and Behavior. 25 (3) (pp 303-306), 2012. Uysal-Soyer O, Yalnizoglu D, Turanli G. The classification and differential diagnosis of absence seizures with short-term video-EEG monitoring during childhood. Turkish Journal of Pediatrics. 54 (1) (pp 7-14), 2012. Wilfong A. Clinical and laboratory diagnosis of seizures in infants and children. UpToDate. July 24, 2012. Williams K, Jarrar R, Buchhalter J. Continuous video-EEG monitoring in pediatric intensive care units. Epilepsia. 52 (6) (pp 1130-1136), 2011. Zsuzsa S, Ideggyogy Sz. 10 years, 600 monitoring sessions, our experience with the video EEG monitoring of children. 30-MAR-2013; 66(3-4): 107-14.

References - Update August 2012 1. 2.

Baheti NN, Radhakrishnan A, Radhakrishnan K. A critical appraisal on the utility of long-term video-EEG monitoring in older adults. Epilepsy Res. 2011 Nov;97(1-2):12-9. Skjei KL, Dlugos DJ. The evaluation of treatment-resistant epilepsy. Semin Pediatr Neurol. 2011 Sep;18(3):150-70.

References – Update September 2011 1. 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):97-100. Nash KB, Bonifacio SL, Glass HC, et al. Video-EEG monitoring in newborns with hypoxic-ischemic encephalopathy treated with hypothermia. Neurology. 2011;76(6):556-562.

References – Update March 2011 1.

Boon P, Michielsen G, Goossens L, et al. Interictal and ictal video-EEG monitoring. Acta Neurol Belg. 1999 Dec;99(4):247-55.

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4. 5. 6. 7.

Consensus statements, sample statutory provisions, and model regulations regarding driver licensing and epilepsy. American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America. Epilepsia 1994; 35:696 Fisher, RS, Parsonage, M, Beaussart, M, et al. Epilepsy and driving: an international perspective. Joint Commission on Drivers' Licensing of the International Bureau for Epilepsy and the International League Against Epilepsy. Epilepsia 1994; 35:675. Friedman, DE, Hirsch, LJ. How long does it take to make an accurate diagnosis in an epilepsy-monitoring unit? J Clin Neurophysiol 2009; 26:213. Thomas, RH, King, WH, Johnston, JA, Smith, PE. Awake seizures after pure sleep-related epilepsy: a systematic review and implications for driving law. J Neurol Neurosurg Psychiatry 2010; 81:130 Ghougassian DF, d'Souza W, Cook MJ, O'Brien TJ. Evaluating the utility of inpatient video-EEG monitoring. Epilepsia. 2004 Aug;45(8):928-32. Kamel JT, Christensen B, Odell MS, et al. Evaluating the use of prolonged videoEEG monitoring to assess future seizure risk and fitness to drive. Epilepsy Behav. 2010 Dec;19(4):608-11

References – Update January 2011 1. 2. 3. 4. 5. 6. 7. 8. 9.

Alving J, Beniczky S. Diagnostic usefulness and duration of the inpatient longterm video-EEG monitoring: findings in patients extensively investigated before the monitoring. Seizure. 2009 Sep;18(7):470-3. Badawy RA, Pillay N, Jetté N, et al. 2.A blinded comparison of continuous versus sampled review of video-EEG monitoring data. Clin Neurophysiol. 2010 Dec 10 Carrette E, Vonck K, De Herdt V, et al. Predictive factors for outcome of invasive video-EEG monitoring and subsequent resective surgery in patients with refractory epilepsy. Clin Neurol Neurosurg. 2010 Feb;112(2):118-26. Dobesberger J, Walser G, Unterberger I, et al. Video-EEG monitoring: Safety and adverse events in 507 consecutive patients. Epilepsia. 2010 Nov 18. doi: 10.1111/j.1528-1167.2010.02782.x. Lee YY, Lee MY, Chen IA, et al. Long-term video-EEG monitoring for paroxysmal events. Chang Gung Med J. 2009 May-Jun;32(3):305-12. Moien-Afshari F, Griebel R, Sadanand V, et al. Safety and yield of early cessation of AEDs in video-EEG telemetry and outcomes. Can J Neurol Sci. 2009 Sep;36(5):587-92. Noe KH, Drazkowski JF. Safety of long-term video-electroencephalographic monitoring for evaluation of epilepsy. Mayo Clin Proc. 2009 Jun;84(6):495-500. Riquet A, Lamblin MD, Bastos M, et al. Usefulness of video-EEG monitoring in children. Seizure. 2010 Oct 14. Villanueva V, Gutiérrez A, García M, et al. Usefulness of Video-EEG monitoring in patients with drug-resistant epilepsy. Neurologia. 2010 Dec 8.

References - Update October 2005 1. 2. 3. 4.

Krumholz A, Hopp J. Psychogenic (nonepileptic) seizures. Semin Neurol. 2006;26(3):341-350. Papacostas SS, Myrianthopoulou P, Papathanasiou E. Epileptic seizures followed by nonepileptic manifestations: A video-EEG diagnosis. Electromyogr Clin Neurophysiol. 2006;46(6):323-327. Benbadis SR. The EEG in nonepileptic seizures. J Clin Neurophysiol. 2006; 23:340-52. de Vries LS, Toet MC. Amplitude integrated electroencephalography in the fullterm newborn. Clin Perinatol. 2006;33:619-32.

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5. 6.

Huszar L, Passaro EA, Talavera F,et al. EEG in dementia and encephalopathy. Updated May 2006. Available at: Lobello K, Morgenlander JC, Radtke RA, et al. Video/EEG monitoring in the evaluation of paroxysmal behavioral events: duration, effectiveness, and limitations. Epilepsy & Behavior.2006;8:261-6.

References – Initial 1. Ghougassian DF, d'Souza W, Cook MJ, Evaluating the utility of inpatient video-

EEG monitoring. Epilepsia. 2004 Aug;45(8):928-32. 2. Rose AB, McCabe PH, Gilliam FG, Consortium for Research in Epilepsy.

3. 4.

5. 6.


8. 9.



Occurrence of seizure clusters and status epilepticus during inpatient video-EEG monitoring. Neurology. 2003 Mar 25;60(6):975-8. Asano E, Pawlak C, Shah A, et al. The diagnostic value of initial video-EEG monitoring in children-Review of 1000 cases. Epilepsy Res. 2005 Sep 9. Guerreiro CA, Montenegro MA, Kobayashi E, et al Daytime outpatient versus inpatient video-EEG monitoring for presurgical evaluation in temporal lobe epilepsy. J Clin Neurophysiol. 2002 Jun;19(3):204-8. Abubakr A, Wambacq I. Seizures in the elderly: Video/EEG monitoring analysis. Epilepsy Behav. 2005 Sep 13. Benbadis SR, O'Neill E, Tatum WO, et al. Outcome of prolonged video-EEG monitoring at a typical referral epilepsy center. Epilepsia. 2004 Sep;45(9):11503. Claassen J, Mayer SA, Kowalski RG, et al. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology. 2004 May 25;62(10):1743-8. Alsaadi T, Marquez A, Psychogenic Nonepileptic Seizures. American Family Physician. 2005 Sep 1. Wood B, Haque S, Weinstock A, et al. Pediatric stress-related seizures: conceptualization, evaluation, and treatment of nonepileptic seizures in children and adolescents. Current Opinion in Pediatrics. 16(5):523-531, October 2004. 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 May:46 (5) 716. Shneker B, Epilepsy. Dis Mon; 49(7): 426-78, Jul 2003.

References - Initial 1. American Electroencephalographic society. Guidelines in electroencephalography, evoked potentials, and polysomnography. J Clin Neurophysiol 1994; 11:1. 2. Aminoff, MJ. Electrodiagnosis in Clinical Neurology, Churchill Livingstone, New York 1998. 3. Bazil CW, Castro LHM, Walczak TS. Diurnal and nocturnal seizures reduce REM in patients with temporal lobe epilepsy. Arch Neurol 2000;57:363–368. 4. Bowman ES, Coons PM. The differential diagnosis of epilepsy, pseudoseizures, dissociative identity disorder, and dissociative disorder not otherwise specified. Bull Menninger Clin. 2000;64(2):164-180. 5. Cascino GD. Clinical indications and diagnostic yield of videoelectroencephalographic monitoring in patients with seizures and spells. Mayo Clin Proc. 2002;77(10):1111-1120. 6. Cascino GD. Use of routine and video electroencephalography. Neurol Clin. 2001;19(2):271-287. 7. Cascino GD. Video-EEG monitoring in adults. Epilepsia. 2002;43 Suppl 3:80-93.

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8. Gilbert, DL, Sethuraman, G, Kotagal, U, Buncher, CR. Meta-analysis of EEG test performance shows wide variation among studies. Neurology 2003; 60:564. 9. Goodin, DS, Aminoff, M, Laxer, K. Detection of epileptiform activity by different non-invasive EEG methods in complex partial epilepsy. Ann Neurol 1990; 27:330. 10. Gotman, J, Marciani, MG. Elelectoencephographic spiking activity, drug levels, and seizure occurrence in epileptic patients. Ann Neurol 1985; 17:597. 11. Herman ST, Walczak TS, Bazil CW. Distribution of partial seizures during the sleep-wake cycle: differences by seizure onset site. Neurol-ogy 2001;56:1453– 1458. 12. Jones, SJ. Short latency potentials recorded from the neck and scalp following median nerve stimulation in man. Electroencephalogr Clin Neurophysiol 1977; 43:853. 13. Malow BA, Bowes RJ, Lin X. Predictors of sleepiness in epilepsy patients. Sleep 1997;20:1105–1110. 14. Mendez M, Radtke RA. Interactions between sleep and epilepsy. J Clin Neurophysiol 2001;18:106–127. 15. Niedermeyer, E, Lopes da Silva, F. Electroencephalography: Basic principles, clinical applications, and related fields, third edition, Williams and Wilkins, Baltimore 1993. 16. Nuwer, MR. Fundamentals of evoked potentials and common clinical applications today. Electroencephalogr Clin Neurophysiol 1998; 106:142. 17. Ross SD, Estok R, Chopra S, et al. Management of newly diagnosed patients with epilepsy: A systematic review of the literature. Evidence Report/Technology Assessment No. 39 (Contract 290-97-0016 to MetaWorks, Inc.). AHRQ Publication No. 01-E038. Rockville, MD: Agency for Healthcare Research and Quality; September 2001. 18. Schaul, N. The fundamental neural mechanisms of electroencephalography. Electroencephalogr Clin Neurophysiol 1998; 106:101. 19. Sheth RD. Intractable pediatric epilepsy: Presurgical evaluation. Semin Pediatr Neurol. 2000;7(3):158-165. 20. Stockard, JJ, Pope-Stockard, JE, Sharbrough, FW. Brainstem auditory evoked potentials in neurology: Methodology, interpretation and clinical applications. In: Aminoff, M, (Ed), In: Electrodiagnosis in clinical neurology, third edition, Churchill-Livingstone, New York 1992.p.503. 21. Thompson JL, Ebersole JS. Long-term inpatient audiovisual scalp EEG monitoring. J Clin Neurophysiology. 1999; 16(2):91-99. 22. Westmoreland BF. The electroencephalogram in patients with epilepsy. In Aminoff MJ, ed. Neurology Clinics. Philadelphia, PA: WB Saunders Co; 1985: 599613. 23. Zivin L, Ajmone-Marsan C. Incidence and prognostic significance of epileptiform activity in the EEG of nonepileptic subjects. Brain. 1996; 91:751-778. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered,

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