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    v1.0.28
    OpenPayerPolicy UpdatesNeurology/NeurosurgeryAmbetter Nevada CPT 95957 Coverage Update | OpenPa…
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    CurrentAmbetter NevadaPolicy CP.MP.105

    Digital EEG Spike Analysis

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    Defines medical necessity and coding for digital EEG spike analysis (CPT 95957) for pre-surgical evaluation of intractable epilepsy; not medically necessary for other indications. Applies to Centene-affiliated health plans and members receiving EEG services.

    Policy Summary
    PayerAmbetter Nevada
    PolicyDigital EEG Spike Analysis
    Policy CodePolicy CP.MP.105
    Change TypeCoding clarification and billing conjunction updates
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization/verification confirming CPT 95957 is billed with an appropriate video EEG code and a qualifying ICD-10 diagnosis from Table 2.
    SourceLink
    POLICY UPDATE CHANGES

    Noted in criteria statements I and II that code in question is 95957.

    Removed video EEG codes from Table 1 and added them to the label for Table 1, specifying that 95957 is medically necessary when billed in conjunction with a video EEG code and a diagnosis code in Table 2.

    In the coding description for 95957, added a note that it is performed in conjunction with any of the CPT codes listed (95718, 95720, 95722, 95724, 95726).

    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.

    1Primary CPT code specified for policy (95957)
    >=30ICD-10 codes supporting medical necessity
    2Policy stances
    5Supporting procedure codes

    Coverage Criteria

    Initial / Presurgical Evaluation

    Covered when ALL of the following are met:

    I. Presurgical evaluation indication: Digital EEG spike analysis (CPT 95957), including topographic voltage and/or dipole analysis, is medically necessary for the pre-surgical evaluation of members/enrollees with intractable epilepsy.

    Must be performed in conjunction with video EEG long-term monitoring (video EEG code) and a diagnosis from Table 2.

    Required conjunction: Performed in conjunction with video EEG long-term monitoring and with a diagnosis of intractable epilepsy (see supporting ICD-10 codes in Table 2).

    Policy states 95957 is medically necessary only when billed in conjunction with video EEG long-term monitoring for presurgical evaluation.

    Not Medically Necessary - Other Indications

    II. Other indications: Digital EEG spike analysis (CPT 95957) is not medically necessary for any indication outside the pre-surgical evaluation of intractable epilepsy.

    CPT 95957 is limited to the presurgical evaluation use described in this policy.

    Billing for digital EEG spike analysis (CPT 95957) is limited to situations where the service represents more than merely recording the EEG on digital equipment. Documentation must show that substantial additional quantitative digital analysis was medically necessary and performed (for example, data selection, quantitative software processing, or dipole source analysis/3D dipole localization). Routine digital recording or automatic spike detection alone does not justify billing 95957.

    CPT 95957 (digital analysis of electroencephalogram for epileptic spike analysis) is considered not medically necessary for any indication except when performed for the pre-surgical evaluation of intractable epilepsy in conjunction with video EEG long-term monitoring.

    Coding

    Primary Covered CPT CodeCPTCovered
    95957Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)
    Procedure codes that support medical necessity when performed in conjunctionCPT
    95718
    95720
    95722
    95724
    95726
    ICD-10 Codes Supporting Medical Necessity (Table 2)ICD-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 epilepticus
    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 26
    1/3

    Provider Actions and Billing Requirements

    Prior Authorization

    Prior authorization: confirm 95957 billed with video EEG code and Table 2 diagnosis

    Prior authorization or verification must confirm that CPT 95957 (digital analysis of electroencephalogram) is billed in conjunction with an appropriate video EEG long-term monitoring procedure code (one of the supporting procedure codes listed) and with a qualifying ICD-10 diagnosis from Table 2 for pre-surgical evaluation of intractable epilepsy.

    • Verify CPT 95957 is submitted with a video EEG long-term monitoring code (see supporting procedure codes list).
    • Confirm the member has a qualifying ICD-10 intractable epilepsy diagnosis from Table 2.
    Step Therapy

    Step therapy: Not applicable

    No step therapy requirements apply to CPT 95957; there are no specified prior steps or trials required before authorization of digital EEG spike analysis for presurgical evaluation.

    Background

    Digital EEG spike analysis, often referred to as 3D dipole localization, is an advanced quantitative technique applied to digitally recorded EEG spikes. It involves deliberate data selection, processing with quantitative software, and dipole source analysis to model the probable intracranial origin of interictal epileptiform discharges. This modality is distinct from routine digital or ambulatory EEG (which commonly use automatic spike detection) and is typically performed at specialty centers as part of comprehensive presurgical evaluation.

    Evidence and specialty guidance note that 3D spike dipole source analysis can be concordant with other presurgical evaluation methods—including video EEG, MRI, electrocorticography, and magnetoencephalography—and is therefore used specifically to help localize epileptogenic foci when preparing a patient with intractable epilepsy for potential surgery.

    Definitions

    Digital EEG spike analysis / 3D dipole localization — definition and components
    TermDigital EEG spike analysis (3D dipole localization)
    Core componentsTopographic voltage mapping (topographic voltage) and dipole/source analysis (dipole source imaging)
    Required analytic stepsData selection and quantitative software processing beyond routine digital recording or automatic spike detection
    PerformersAnalysis performed by a technician and a physician
    Clinical usePrimarily used for presurgical (pre‑resection) evaluation of intractable epilepsy to localize epileptogenic foci

    Revision History

    2024-09-24annual review

    Annual review: background updated with no impact on criteria; references reviewed and updated.

    2024-05-24coding clarification

    In the coding description for CPT 95957, restored a note stating it is performed in conjunction with specified CPT codes (previously removed in error).

    2024-01-24coding update

    Added new 2024 ICD-10 codes G40.C11 and G40.C19 to the ICD-10 coding table.

    Policy Summary
    PayerAmbetter Nevada
    PolicyDigital EEG Spike Analysis
    Policy CodePolicy CP.MP.105
    Change TypeCoding clarification and billing conjunction updates
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization/verification confirming CPT 95957 is billed with an appropriate video EEG code and a qualifying ICD-10 diagnosis from Table 2.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions and Billing RequirementsBackgroundDefinitionsRevision History
    Documentation Required

    Required documentation: show substantial additional quantitative analysis

    Documentation must demonstrate that substantial additional quantitative digital analysis was medically necessary and performed (for example, data selection, quantitative software processing, and dipole source analysis/3D dipole localization), not merely that the EEG was recorded on digital equipment.

    • Record of quantitative software processing and dipole/source analysis performed.
    • Evidence that analysis went beyond routine digital recording or automatic spike detection and was required for presurgical evaluation.
    Denial Risk

    Denial triggers for CPT 95957

    Claims for CPT 95957 will be denied if the service was not performed for presurgical evaluation of intractable epilepsy or if 95957 is not billed in conjunction with an appropriate video EEG code and a supporting Table 2 diagnosis.

    • Billing 95957 for indications other than pre-surgical evaluation of intractable epilepsy will be denied.
    • Billing 95957 without an accompanying video EEG long-term monitoring code and a Table 2 ICD-10 diagnosis will be denied.
    2023-09-23annual review

    Annual review with minor rewording in Criteria I; background updated with no impact on criteria; references reviewed and updated.

    2023-09-25annual review and coding updateLatest

    Annual review noting 95957 identified in criteria I and II; removed video EEG codes from Table 1 and added them to Table 1 label specifying 95957 is medically necessary when billed with a video EEG code and a Table 2 diagnosis; added codes G40.843 and G40.844 to Table 2.