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

    Digital EEG Spike Analysis

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    Coverage and medical necessity for additional digital EEG spike analysis, including topographic voltage and dipole analysis, limited to presurgical evaluation of members with intractable epilepsy in conjunction with video EEG long-term monitoring.

    Policy Summary
    PayerAmbetter Nevada
    PolicyDigital EEG Spike Analysis
    Policy CodePolicy CP.MP.105
    Change TypeModified
    Effective DateN/A
    Last ReviewJan 1, 2024
    Next Review DateN/A
    Key ActionDocument presurgical evaluation for intractable epilepsy, video EEG long-term monitoring, and substantial additional digital spike analysis.
    SourceLink
    POLICY UPDATE CHANGES

    The January 2024 revision added ICD-10-CM codes G40.C11 and G40.C19 to the coding table.

    The September 2023 annual review made minor wording changes to Criteria I without changing the coverage criteria.

    1Covered clinical indication
    Not coveredOther indications
    5Supporting procedure codes
    20Supporting diagnosis 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.

    2New diagnosis codes
    Take precedenceMedicaid provisions

    Coverage Criteria

    Presurgical evaluation of intractable epilepsy

    Covered when all of the following are met:

    Covered indication: Digital electroencephalography (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.

    Do not use digital EEG spike analysis assessment or billing solely because the EEG was recorded on digital equipment. The service is reserved for cases in which substantial additional digital analysis was medically necessary and performed, such as 3D dipole localization, beyond routine digital recording or automatic spike detection.

    Digital EEG spike analysis is medically necessary only for the presurgical evaluation of members/enrollees with intractable epilepsy when performed in conjunction with video EEG long-term monitoring. It is not medically necessary for any other indication.

    Digital EEG spike analysis is not medically necessary for any other indication outside the qualifying presurgical evaluation of intractable epilepsy performed with video EEG long-term monitoring.

    Supporting 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
    G40.411Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
    G40.419Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
    1–10 of 23
    1/3

    Provider Requirements and Denial Risks

    Documentation Required

    Support Presurgical Evaluation and Additional Analysis

    Support digital EEG spike analysis for the pre-surgical evaluation of members/enrollees with intractable epilepsy when performed in conjunction with video EEG long-term monitoring. Document that substantial additional digital analysis was medically necessary and performed beyond routine digital recording, such as 3D dipole localization, including the associated technician processing and physician review.

    • Confirm the indication is pre-surgical evaluation for intractable epilepsy.
    • Confirm video EEG long-term monitoring was performed in conjunction with the analysis.
    • Document the additional analysis performed, such as 3D dipole localization, rather than merely recording the EEG on digital equipment.
    • Ambulatory EEG is not appropriate for the detailed characterization required for presurgical evaluation.

    Policy Background

    Digital EEG spike analysis is additional analysis of digitally recorded EEG spikes, also known as 3D dipole localization or dipole source imaging. It is distinct from routine EEG recording on digital equipment and from automatic spike detection. The additional work includes substantial processing of the digital EEG data by a technician and physician review of the technician’s work and the resulting data; the policy describes approximately 1 additional hour of technician work and 20 to 30 minutes of physician review in the applicable circumstances.

    Key Definitions

    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 EEG spike analysis beyond the digital recording itself.
    Additional digital analysis
    DefinitionAnalysis beyond automatic spike detection or the use of digital recording equipment alone.
    Required workSubstantial additional digital analysis that is medically necessary and performed.
    Example
    Policy Summary
    PayerAmbetter Nevada
    PolicyDigital EEG Spike Analysis
    Policy CodePolicy CP.MP.105
    Change TypeModified
    Effective DateN/A
    Last ReviewJan 1, 2024
    Next Review DateN/A
    Key ActionDocument presurgical evaluation for intractable epilepsy, video EEG long-term monitoring, and substantial additional digital spike analysis.
    SourceLink
    On This Page
    Coverage CriteriaSupporting CodesProvider Requirements and Denial RisksPolicy BackgroundKey Definitions
    Billing Rule

    Review Medicare Coverage Requirements

    For Medicare members/enrollees, review applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying this clinical policy.

    • Refer to the CMS website for current Medicare coverage requirements and applicable guidance.
    Denial Risk

    Noncovered Indications and Routine Digital Recording

    Digital EEG spike analysis is not medically necessary for indications other than the presurgical evaluation of intractable epilepsy. Do not report the service when the EEG was only recorded on digital equipment or when no substantial additional digital analysis was medically necessary and performed.

    • Routine digital EEG recording, including automatic spike detection ordinarily incorporated into digital, ambulatory, video, or routine EEG, does not by itself constitute digital EEG spike analysis.
    • Deny or do not use digital EEG spike analysis assessment and billing for non-presurgical indications.
    • Additional analysis must involve work beyond routine recording, such as 3D dipole localization, with technician processing and physician review.
    3D dipole localization, including technician processing of digital EEG data and physician review of the work and resulting data.
    Clinical useFurther digital analysis is used in the noninvasive evaluation of candidates for epilepsy surgery.
    Ambulatory EEG
    DefinitionAn EEG monitoring approach that uses digital technology and typically incorporates automatic spike detection.
    ACNS assessmentThe ACNS states that ambulatory EEG is not appropriate for detailed characterization of EEG features required in presurgical evaluation.
    DistinctionAmbulatory EEG is not the same as digital EEG spike analysis, including 3D dipole localization.