|Highmark Commercial Medical Policy - Pennsylvania|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Transmission of the EEG by telephone, radio, or cable may be considered medically necessary when the closest medical facilities are located in remote areas which lack trained EEG interpreters for patients with the following indications:
Radio and cable telemetry of the EEG may be considered medically necessary for an:
Video EEG monitoring may be considered medically necessary for ANY ONE of the following indications and/or conditions:
Note: Monitoring may be performed on an outpatient or inpatient basis, depending on the frequency and duration of seizure activity and length of time necessary to collect data. Patients with frequent (at least three per week) intractable minor seizures and those patients being evaluated for efficacy of drug treatment can be evaluated on an outpatient basis, in 3-12 hours. Inpatient monitoring is required for patients such as those with seizures that only occur at night, are infrequent, are clinically severe (such as prolonged complex partial seizures), or are provoked by drug withdrawal.
Twenty-four hour ambulatory cassette-recorded EEGs may be medically necessary in the following circumstances:
Quantitative electroencephalogram (QEEG) may be considered medically necessary when used as an adjunct to traditional EEG and/or diagnostic evaluation of epilepsy when ANY ONE of the following criteria is met:
Digital analysis of electroencephalogram (DEEG) is considered not medically necessary as there is no evidence that such additional processing and interpretation has been shown to improve outcomes in patient management.
Twenty-four hour ambulatory cassette-recorded EEGs are considered experimental/investigational and, therefore non-covered in the following circumstances:
Scientific evidence does not demonstrate the efficacy of twenty-four hour ambulatory cassette-recorded EEGs in certain instances.
Telephone transmission of the EEG to determine electrocerebral silence, i.e., brain death, is considered experimental/investigational, and therefore non-covered.
Quantitative electroencephalographic-based assessment (QEEG) is considered experimental/investigational and, therefore non-covered when used as a diagnostic aid for attention deficit/hyperactivity disorder.
Experimental/Investigational (E/I) services are not covered regardless of place of service.
The use of EEG Technologies is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
07/2015, Revised Criteria for EEG Technologies
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.