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    v1.0.28
    OpenPayerPolicy UpdatesNeurology/NeurosurgeryAmbetter Nevada EEG Spike Coverage | OpenPayer
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    CurrentAmbetter NevadaPolicy CP.MP.105

    Digital EEG Spike Analysis

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    This policy governs medical necessity and coding for additional analysis of digitally recorded EEG spikes, including topographic voltage and dipole analysis. Coverage is limited to presurgical evaluation of members with intractable epilepsy when performed with video EEG long-term monitoring.

    Policy Summary
    PayerAmbetter Nevada
    PolicyDigital EEG Spike Analysis
    Policy CodePolicy CP.MP.105
    Change TypeMaterial revision
    Effective DateN/A
    Last ReviewSep 1, 2023
    Next Review DateN/A
    Key ActionDocument intractable epilepsy, the presurgical evaluation purpose, concurrent video EEG long-term monitoring, and the substantial additional analysis performed.
    SourceLink
    POLICY UPDATE CHANGES

    Removed quantitative EEG from the medical-necessity criteria.

    Added CPT codes 95718, 95720, 95722, 95724, and 95726 as new 2020 codes.

    Made minor wording changes to Criterion I during the September 2023 annual review.

    1Covered clinical indication
    5Supporting CPT codes
    20Supporting ICD-10-CM codes

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Not covered
    Other indications
    1 hr + 20–30 minAdditional analysis time

    Medical Necessity Criteria

    Presurgical evaluation of intractable epilepsy

    Covered when ALL of the following are met:

    Covered indication: Digital EEG spike analysis, including topographic voltage and/or dipole analysis, is medically necessary for the presurgical evaluation of a member/enrollee with intractable epilepsy in conjunction with video EEG long-term monitoring.

    All stated elements are required.

    Other indications

    Not medically necessary when the indication is outside the covered presurgical epilepsy evaluation.

    Noncovered indication: Digital EEG spike analysis is not medically necessary for any other indication.

    Any indication other than presurgical evaluation of intractable epilepsy performed in conjunction with video EEG long-term monitoring is noncovered under this policy.

    Digital EEG spike analysis and billing are not appropriate when the EEG was only recorded on digital equipment. The service is reserved for cases in which substantial additional digital analysis was medically necessary and actually performed, such as 3D dipole localization, beyond routine digital recording or automatic spike detection. This additional work generally includes approximately 1 hour of technician processing and 20–30 minutes of physician review.

    Ambulatory EEG is not appropriate for the detailed characterization of EEG features required during presurgical evaluation for epilepsy.

    Digital EEG spike analysis is not medically necessary for any indication other than the presurgical evaluation of a member or enrollee with intractable epilepsy performed in conjunction with video EEG long-term monitoring.

    Supporting Procedure and Diagnosis Codes

    Covered CPT CodesCPTCovered
    95957Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)
    95720Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, each increment of greater than 12 hours, up to 26 hours of EEG recording; with video (VEEG)
    95722Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, with video (VEEG)
    95724Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84 hours of EEG, with video (VEEG)
    95726Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG recording, with video (VEEG)
    Covered ICD-10-CM Diagnosis CodesICD-10Covered
    G40.011Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus
    G40.019Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
    G40.111Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
    G40.119Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
    G40.211Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
    G40.219Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status
    G40.311Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
    G40.319Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
    G40.419Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
    G40.804Other epilepsy, intractable, without status epilepticus
    1–10 of 20
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    Documentation and Billing Guidance

    Documentation Required

    Document the presurgical evaluation and additional analysis

    Document that digital EEG spike analysis, including topographic voltage and/or dipole analysis, is medically necessary for the pre-surgical evaluation of a member/enrollee with intractable epilepsy and is performed in conjunction with video EEG long-term monitoring. Also document that substantial additional digital analysis was medically necessary and performed, including technician processing and physician review of the technician’s work and resulting data.

    • Record the intractable epilepsy diagnosis and presurgical evaluation purpose.
    • Identify the concurrent video EEG long-term monitoring.
    • Describe the substantial additional analysis performed, such as 3D dipole localization.
    • Document technician processing and physician review of the work and resulting data.
    Denial Risk

    Avoid noncovered indications

    Clinical Background

    Digital EEG spike analysis—also called 3D dipole localization or dipole source analysis—is a more detailed evaluation of digitally recorded EEG spikes performed by a technician and physician. Its clinical purpose is to provide additional information during the noninvasive presurgical evaluation of patients with intractable epilepsy, particularly when identifying epileptogenic foci may support evaluation for epilepsy surgery.

    Terminology

    Digital EEG spike analysis
    DefinitionAdditional analysis of digitally recorded EEG spikes performed by a technician and a physician.
    Also known as3D dipole localization or dipole source imaging.
    PurposeProvides additional analysis beyond the digital EEG recording and its automatically detected spikes.
    Substantial additional digital analysis
    DefinitionAnalysis beyond automatic digital spike detection that involves substantial additional processing of the digital EEG data.
    Example3D dipole localization is an example of substantial additional digital analysis.
    Policy Summary
    PayerAmbetter Nevada
    PolicyDigital EEG Spike Analysis
    Policy CodePolicy CP.MP.105
    Change TypeMaterial revision
    Effective DateN/A
    Last ReviewSep 1, 2023
    Next Review DateN/A
    Key ActionDocument intractable epilepsy, the presurgical evaluation purpose, concurrent video EEG long-term monitoring, and the substantial additional analysis performed.
    SourceLink
    On This Page
    Medical Necessity CriteriaSupporting Procedure and Diagnosis CodesDocumentation and Billing GuidanceClinical BackgroundTerminology

    Digital EEG spike analysis is not medically necessary for any indication other than presurgical evaluation of a member/enrollee with intractable epilepsy performed in conjunction with video EEG long-term monitoring. Claims for other indications may be denied under this policy.

    Billing Rule

    Digital recording alone does not support billing

    Do not bill digital EEG spike analysis merely because the EEG was recorded on digital equipment. Assessment and billing are reserved for cases in which substantial additional digital analysis was medically necessary and actually performed, such as 3D dipole localization.

    • Routine, ambulatory, and video EEG may use digital technology and automatic spike detection, but those services are not the same as digital EEG spike analysis.
    • The policy describes approximately one additional hour of technician processing and 20–30 minutes of physician review for substantial additional analysis.
    Denial Risk

    Do not use ambulatory EEG for presurgical characterization

    Do not use ambulatory EEG for the detailed characterization of EEG features required in presurgical evaluation. The policy states that ambulatory EEG is not appropriate for this purpose.

    Technician time
    Approximately 1 additional hour to process the digital EEG data.
    Physician timeAn additional 20 to 30 minutes for the physician to review the technician's work and the resulting data.
    Automatic spike detection versus digital EEG spike analysis
    Routine EEG servicesRoutine, ambulatory, and video EEG use digital technology and usually incorporate automatic spike detection.
    Automatic detectionAutomatic spike detection is part of the digital EEG technology and does not, by itself, constitute digital EEG spike analysis.
    Separate analysisDigital EEG spike analysis is reserved for medically necessary, substantial additional digital analysis, such as 3D dipole localization, that is actually performed.
    Ambulatory EEGAmbulatory EEG is not appropriate for the detailed characterization of EEG features required in presurgical evaluation.