Baylor Scott & White epilepsy surgery Coverage

Coverage Criteria for Invasive Seizure Treatments

Resective surgery and LITT general medical necessity

BSWHP may consider cerebral hemispherectomy, corpus callosotomy, and temporal lobectomy medically necessary when ALL of the following criteria are met:

Surgery general criteria: 1. Member is at least 18 years old OR under 18 years of age with a suitable pediatric seizure diagnosis (e.g., unilateral multi-focal epilepsy associated with infantile hemiplegia as seen in hemimegaloencephaly and Sturge-Weber disease); AND 2. Non-epileptic events or conditions (e.g., cardiogenic syncope, psychogenic seizures) have been ruled out; AND 3. The diagnosis of epilepsy has been documented and the epileptic seizure type and epileptic syndrome have been clearly defined; AND 4. Seizures occur at a frequency that interferes with daily living and threatens the member's wellbeing; AND 5. There has been an adequate trial of drug therapy with at least two appropriate antiepileptic medications at therapeutic levels with member compliance OR the member has failed at least two drug therapies due to medication toxicity/adverse effects; AND 6. The individual is not a candidate for OR has failed invasive neurostimulation therapy.

Applies to cerebral hemispherectomy, corpus callosotomy, and temporal lobectomy.

LITT (Laser interstitial thermal therapy)

For LITT (including magnetic resonance-guided systems) the surgical criteria above must be met AND ALL of the following additional criteria:

LITT-specific criteria: 1. There are LITT-accessible, well-defined epileptogenic foci; AND 2. LITT is determined to be the best treatment option by a multidisciplinary physician team of at least two specialties (e.g., neurosurgery, neurology).

Includes MR-guided LITT systems (e.g., NeuroBlate, Visualase).

Anterior nucleus of the thalamus (DBS) coverage criteria

BSWHP may consider bilateral stimulation of the anterior nucleus of the thalamus medically necessary when ALL of the following are met:

ANT-DBS criteria: 1. Member is at least 18 years old; AND 2. The diagnosis of partial-onset seizure with or without secondary generalization to tonic-clonic activity is documented; AND 3. There has been an adequate trial of drug therapy with at least three appropriate antiepileptic medications at therapeutic levels with member compliance OR the member has failed at least three drug therapies due to medication toxicity/adverse effects; AND 4. Seizures occur at a frequency (average of at least 6 per month over the previous 3-month period, with no more than 30 days between seizures) that interferes with daily living and threatens the member's well-being.Seizure frequency >=6/month over prior 3 months

Reserved for adults meeting these medication and seizure-frequency thresholds.

Responsive neurostimulation (RNS) criteria

BSWHP may consider responsive neurostimulation (RNS) (e.g., the NeuroPace RNS System) medically necessary for adults with intractable focal (partial-onset) seizures when ALL of the following are met:

RNS criteria: 1. Member is at least 18 years old; AND 2. Non-epileptic events or conditions (e.g., cardiogenic syncope, psychogenic seizures) have been ruled out; AND 3. The diagnosis of epilepsy has been documented and the epileptic seizure type and epileptic syndrome have been clearly defined; AND 4. Seizures (e.g., motor partial seizures, complex partial and/or secondarily generalized seizures) occur at a frequency (average of at least 3 per month over the previous 3-month period) that interferes with daily living and threatens the member's well-being; AND 5. There has been an adequate trial of drug therapy with at least two appropriate antiepileptic medications at therapeutic levels with member compliance; AND 6. The member has no more than two epileptogenic regions; AND 7. Member is not a candidate for resective epilepsy surgery because the epileptic focus is near regions of concern (e.g., language or memory); AND 8. Member has the ability, or has the necessary assistance, to properly operate the device; AND 9. Member has none of the following contraindications: three or more specific seizure foci, presence of generalized epilepsy, presence of a rapidly progressive neurologic disorder, or presence of other implanted medical devices that deliver electrical energy to the brain.Seizure frequency >=3/month over prior 3 months

RNS is considered experimental, investigational, or unproven for all other indications beyond those listed.

Vagus nerve stimulation (VNS) criteria

For non-responsive (open loop) VNS (applies to non‑Medicare plans), BSWHP may consider VNS medically necessary when ALL of the following are met:

VNS criteria: 1. There has been an adequate trial of drug therapy with at least two appropriate antiepileptic medications at therapeutic levels with member compliance OR the member has failed at least two drug therapies due to medication toxicity/adverse effects; AND 2. Member does not have a contraindication to vagus nerve stimulation (e.g., history of left or bilateral cervical vagotomy).

For Medicare plans, follow NCD 160.18; responsive/closed-loop and transcutaneous VNS are unproven and not medically necessary.

Responsive (closed-loop) and transcutaneous (non-implantable) vagus nerve stimulation (VNS) devices are explicitly classified as unproven and not medically necessary because current evidence is insufficient to demonstrate efficacy for the treatment of epilepsy.

Cerebellar stimulation and deep brain stimulation (DBS) targeted to sites other than the anterior nucleus of the thalamus are considered experimental and investigational for treatment of intractable seizures; their effectiveness for this indication has not been established.

Localized neocortical resections for uncontrolled complex partial seizures are considered experimental and investigational because their effectiveness for this indication has not been established.

Hippocampal electrical stimulation for mesial‑temporal lobe epilepsy is considered experimental and investigational because available evidence does not establish its effectiveness.

Stereotactic radiosurgery, including techniques such as radiofrequency amygdalohippocampectomy for medial temporal lobe epilepsy or epilepsy arising in other functional cortical regions, is considered experimental and investigational due to insufficient evidence of effectiveness.

Responsive neurostimulation (RNS) is covered only for the specific indications and selection criteria detailed elsewhere in this policy; RNS is considered experimental, investigational, or unproven for all other indications beyond those listed.

Cerebral hemispherectomy, corpus callosotomy, and temporal lobectomy are considered experimental and investigational when the policy's required selection criteria are not met; these resections are medically necessary only when all specified criteria are satisfied and documented.

Use of High‑Frequency Oscillations in epilepsy surgery planning is considered experimental and investigational because its effectiveness has not been established.

For clarity, responsive (closed‑loop) and transcutaneous VNS devices are stated as not medically necessary due to insufficient evidence of efficacy supporting their use for epilepsy treatment.

Billing and Diagnosis Codes

Covered CPT CodesCPTCovered

61534	Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery
61536	Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array)
61537	Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, without electrocorticography during surgery
61538	Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with electrocorticography during surgery
61541	Craniotomy with elevation of bone flap; for transection of corpus callosum
61543	Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy
61736	Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance; single trajectory for 1 simple lesion
61737	Laser interstitial thermal therapy (LITT) of lesion, intracranial; multiple trajectories for multiple or complex lesion(s)
61850	Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical
61860	Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical

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Potential ICD-10 CodesICD-10

G40.011	Localization-related (focal) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus
G40.019	Localization-related (focal) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
G40.111	Localization-related (focal) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
G40.119	Localization-related (focal) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
G40.211	Localization-related (focal) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
G40.219	Localization-related (focal) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
G40.311	Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319	Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.411	Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419	Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus

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Seizure frequency thresholds — RNS and DBS (ANT)

RNS (Responsive Neurostimulation) seizure-frequency thresholdAverage ≥3 seizures per month, measured over the previous 3-month period

RNS timing window for measurementFrequency calculated as the average over the prior 3 months

ANT-DBS (Anterior nucleus DBS) seizure-frequency thresholdAverage ≥6 seizures per month, measured over the previous 3-month period

ANT-DBS maximum inter-seizure interval requirementNo more than 30 days between seizures within the 3-month measurement period

ANT-DBS timing window for measurementFrequency calculated as the average over the prior 3 months

Provider Actions and Authorization Requirements

Prior Authorization

Prior authorization required for procedures and planning

Prior authorization is required for all procedures and for planning procedures if epilepsy surgery is under consideration.

Note

Prior authorization procedures/codes not specified in excerpt

The policy names the service (Seizure Disorders: Invasive Treatments) but this excerpt does not list explicit prior authorization procedures or affected billing codes.

Step Therapy

Medication trial requirements (adequate AED trials)

Coverage requires prior adequate trials of antiepileptic drugs before surgical or device interventions; counts vary by procedure.

Background

Patients with intractable epileptic seizures—that is, seizures that persist despite adequate trials of appropriate antiepileptic drugs—may be considered for surgical or neurostimulation interventions to reduce seizure frequency and improve quality of life. Established evidence-based options include temporal lobectomy, corpus callosotomy, hemispherectomy, and selected neurostimulation therapies (for example, anterior nucleus DBS and VNS under specified criteria). Candidates must be evaluated by a multidisciplinary team, have non‑epileptic events excluded, meet the policy’s age and medication‑trial thresholds, and undergo appropriate pre‑surgical localization and documentation. Prior authorization is required for all procedures and for planning procedures if epilepsy surgery is under consideration.

Definitions

Definition — Intractable epilepsy / drug-resistant epilepsy

Definition — Intractable (drug-resistant) epilepsyEpilepsy that persists despite adequate treatment with appropriate antiepileptic drugs, typically after trials of multiple medications or intolerable toxicity; candidates have seizures despite adequate AED therapy

Required medication trials (policy-level summary)Adequate trials of antiepileptic drugs: generally at least two AEDs failed for most surgical options (RNS/VNS/LITT); three AEDs failed required for ANT-DBS

Clinical exclusion for invasive candidatesCandidates should not have progressive neurologic disease or major uncontrolled medical/psychological disorders; non-epileptic events must be ruled out

Definition — Invasive epilepsy treatments / epilepsy surgery

Resective temporal and neocortical surgeryTemporal lobectomy and localized neocortical resections for focal epileptogenic foci (when a single identifiable focus can be safely excised)

Revision History

06/01/2026Policy effective dateLatest

Policy effective date established for Seizure Disorders: Invasive Treatments (Policy No. 013)

05/28/2026Last review

Clinical policy last reviewed and updated prior to effective date

05/28/2027Next review due

Seizure Disorders: Invasive Treatments (Epilepsy Surgery)

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