Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that an electroencephalogram (EEG) is a diagnostic test that measures the electrical activity of the 
brain (brainwaves) using highly sensitive recording equipment attached to the scalp by fine electrodes. It is 
used to diagnose neurological conditions. 
 
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. Twenty-four-hour ambulatory recorded EEGs offer the 
ability to record the EEG on a long-term, outpatient basis. Recorded electrical activity is analyzed by playback 
through an audio system and/or video monitors. 
 
Ambulatory EEG monitoring may facilitate the differential diagnosis between seizures and syncopal attacks, 
sleep apnea, cardiac arrhythmias, or hysterical episodes. The test may also allow the investigator to identify the 
epileptic nature of some episodic periods of disturbed consciousness, mild confusion, or peculiar behavior, 
where resting EEG is not conclusive. It may also allow an estimate of seizure frequency, which may at times 
help to evaluate the effectiveness of a drug and determine its appropriate dosage. 
 
INDICATIONS: 
 
 Inconclusive routine resting EEGs 
 Experiencing episodic events where epilepsy is suspected but the history, examination, and routine EEG 
recordings do not resolve the diagnostic uncertainties  
 Patients with confirmed epilepsy, who are experiencing suspected non-epileptic events or for classification of 
seizure type (only ictal recordings can reliably be used to classify seizure type(s)), which is important in 
selecting appropriate anti-epileptic drug therapy 
 Differentiating between neurological, cardiac, and psychiatric related problems 
 Localizing seizure focus for enhanced patient management 
 Identifying and medicating absence seizures 
 For suspected seizures of sleep disturbances 
 Seizures which are precipitated by naturally occurring cyclic events or environmental stimuli which are not 
reproducible in the hospital or clinic setting 
 
 
 
 Ambulatory monitoring; however, is not necessary to evaluate most seizures, which are usually readily 
diagnosed by routine EEG studies and history. Medicare anticipates that many of these outpatient studies will 
not provide the diagnosis within the first 24 hours but expects that 48 hours of monitoring will be diagnostic in 
most circumstances. Ambulatory monitoring beyond 48 hours frequently produces poor data in the period after 
48 hours, as electrode contact may no longer be optimal after 48 hours. Occasionally, patients may require an 
additional 48-hour monitoring period to establish a diagnosis, which is usually performed at a later date. 
Medical necessity must be documented for review in these circumstances. This 48-hour limitation does not 
apply to the inpatient setting where patients are frequently withdrawn from their anti-epileptic regimens, and 
where precise pre-surgical localization of epileptic foci is often conducted. 
 
It is anticipated that once the diagnosis has been established, this study will not be repeated for the same 
diagnosis, nor will it be used in the monitoring of a therapeutic regimen. Again, this expectation will not be 
applied to patients readmitted for inpatient care of their seizure disorder. 
 
LIMITATIONS (NON-COVERED INDICATIONS): 
 
 Study of neonates or unattended, non-cooperative patients 
 Localization of seizure focus or foci when the seizure symptoms and/or other EEG recordings indicate the 
presence of bilateral foci or rapid generalization 
 
You can find these rules in the Local Coverage Determination (LCD) Special Electroencephalography L33447. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.