Ambulatory EEG Monitoring (NCD 160.22) – Medicare ...

1 Ambulatory EEG Monitoring (NCD ) Page 1 of 9 UnitedHealthcare Medicare Advantage Policy Guideline Approved 10/13/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Medicare Advantage Policy Guideline Ambulatory EEG Monitoring (NCD ) Guideline Number: Approval Date: October 13, 2021 Terms and Conditions Table of Contents Page Policy Summary .. 1 Applicable Codes .. 1 References .. 7 Guideline History/Revision Information .. 8 Purpose .. 8 Terms and Conditions .. 8 Policy Summary See Purpose Overview Ambulatory or 24-hour electroencephalographic (EEG) Monitoring is accomplished by a cassette recorder that continuously records brain wave patterns during sleep and 24 hours of a patient's routine daily activities.

2 The Monitoring equipment consists of preamplifiers, an electrode set, and a cassette recorder. The electrodes attach to the scalp, and their leads are connected to a recorder. Guidelines Ambulatory EEG Monitoring is a diagnostic procedure for patients in whom a seizure diathesis is suspected but not defined by history, physical or resting EEG. Ambulatory EEG can be utilized in the differential diagnosis of transient ischemic attacks if not elucidated by conventional studies and syncope. Ambulatory EEG should always be preceded by a resting EEG. Ambulatory EEG Monitoring is covered under Medicare for the above purposes. Applicable Codes The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive.

3 Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply. CPT Code Description 95700 Electroencephalogram (EEG) continuous recording, with video when performed, setup, patient education, and takedown when performed, administered in person by EEG technologist, minimum of 8 channels (Effective 01/01/2020) 95705 Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; unmonitored (Effective 01/01/2020) 95708 Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each increment of 12-26 hours.

4 Unmonitored (Effective 01/01/2020) Related Medicare Advantage Policy Guideline Long-Term EEG Monitoring Related Medicare Advantage Coverage Summary Neurologic Services and Procedures Ambulatory EEG Monitoring (NCD ) Page 2 of 9 UnitedHealthcare Medicare Advantage Policy Guideline Approved 10/13/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. CPT Code Description 95717 Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; without video (Effective 01/01/2020) 95719 Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period.

5 Without video (Effective 01/01/2020) 95721 Electroencephalogram (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, without video (Effective 01/01/2020) 95950 Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic ( , 8 channel EEG) recording and interpretation, each 24 hours (Deleted 12/31/2019) 95953 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended (Deleted 12/31/2019)

6 CPT is a registered trademark of the American Medical Association Diagnosis Code Description Tuberculous meningoencephalitis Meningococcal encephalitis Actinomycotic encephalitis Late congenital syphilitic encephalitis Late syphilitic encephalitis Japanese encephalitis Western equine encephalitis Eastern equine encephalitis St Louis encephalitis Australian encephalitis California encephalitis Other mosquito-borne viral encephalitis Mosquito-borne viral encephalitis, unspecified Far Eastern tick-borne encephalitis [Russian spring-summer encephalitis] Central European tick-borne encephalitis Other tick-borne viral encephalitis (Deleted 09/30/2020) Other tick-borne viral encephalitis (Effective 10/01/2020) Tick-borne viral encephalitis, unspecified Enteroviral encephalitis Adenoviral encephalitis Arthropod-borne viral encephalitis, unspecified Other specified viral encephalitis Venezuelan equine fever West Nile virus infection with encephalitis Zika virus disease Varicella encephalitis and encephalomyelitis Ambulatory EEG Monitoring (NCD )

7 Page 3 of 9 UnitedHealthcare Medicare Advantage Policy Guideline Approved 10/13/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Diagnosis Code Description Zoster encephalitis Measles complicated by encephalitis Rubella encephalitis Human herpesvirus 6 encephalitis Other human herpesvirus encephalitis Mumps encephalitis Sequelae of viral encephalitis Conversion disorder with motor symptom or deficit Conversion disorder with seizures or convulsions Conversion disorder with sensory symptom or deficit Conversion disorder with mixed symptom presentation Acute disseminated encephalitis and encephalomyelitis, unspecified Postinfectious acute disseminated encephalitis and encephalomyelitis (postinfectious ADEM)

8 Postimmunization acute disseminated encephalitis, myelitis and encephalomyelitis Acute necrotizing hemorrhagic encephalopathy, unspecified Postinfectious acute necrotizing hemorrhagic encephalopathy Other encephalitis and encephalomyelitis Encephalitis and encephalomyelitis, unspecified Encephalitis and encephalomyelitis in diseases classified elsewhere Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus Localization-related (focal)

9 (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus Localization-related (focal) (partial)

10 Symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus Ambulatory EEG Monitoring (NCD ) Page 4 of 9 UnitedHealthcare Medicare Advantage Policy Guideline Approved 10/13/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Diagnosis Code Description Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus Other generalized epilepsy and epileptic syndro