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Medical Policy: 06.01.09
Original Effective Date: April 2002
Reviewed: February 2012
Revised: January 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Magnetoencephalography (MEG) is a noninvasive functional imaging technique in which the weak magnetic forces associated with the electrical activity of the brain are recorded externally on the scalp. This information can be superimposed on an anatomic image of the brain, typically a magnetic resonance imaging (MRI) scan, to produce a functional anatomic image of the brain, referred to as magnetic source imaging (MSI). The primary advantage of MSI is that while the conductivity and measurement of electrical activity as recorded by the electroencephalogram (EEG) is altered by surrounding brain structures, the magnetic fields are not. Therefore, MSI permits a high resolution image.
The most thoroughly studied clinical application is localization of the pre- and post-central gyri as a guide to surgical planning, in those patients scheduled to undergo neurosurgery for epilepsy, brain neoplasms, arteriovenous malformations or other brain disorders. These gyri contain the sophisticated sensorimotor areas of the brain, the preservation of which is considered critical during any type of brain surgery. In normal situations, these areas can be identified anatomically by MRI, but frequently the anatomy is distorted by underlying disease processes.
Another application is localization of epileptic foci, particularly for screening of surgical candidates and surgical planning.
MSI has principally been investigated as an alternative to invasive monitoring.
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Prior Approval:
Not applicable
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Policy:
Magnetoencephalography (MEG) /Magnetic source imaging (MSI) is considered medically necessary for:
- presurgical evaluation of patients with intractable focal epilepsy to identify and localize area(s) of epileptiform activity, when lack of agreement or questions continue to arise from other techniques designed to specify a focus.
- presurgical identification and localization of eloquent cortex prior to surgical resection of brain tumor or vascular malformation to maximize protection of eloquent cortex.
Magnetoencephalography (MEG) /Magnetic source imaging (MSI) is considered investigational when used as a stand-alone test or as the first order of test after clinical and routine EEG diagnosis of epilepsy.
Magnetoencephalography (MEG) /Magnetic source imaging (MSI) is considered investigational for all other indications including but not limited to: evaluation of persons with Alzheimer’s disease, autism, cognitive and mental disorders, developmental dyslexia, multiple sclerosis, Parkinson’s disease, schizophrenia, stroke rehabilitation, and traumatic brain injury.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 95965 Magnetoencephalography, recording and analysis for spontaneous brain magnetic activity (e.g. epileptic cerebral cortex localization)
- 95966 Magnetoencephalography, recording and analysis for evoked magnetic fields, single modality (eg. Sensory, motor, language, or visual cortex localization)
- 95967 Magnetoencephalography, recording and analysis; for evoked magnetic fields, each additional modality (e.g. sensory, motor, visual cortex, motor or language localization). (List separately in addition to code for primary procedure)
- S8035 - Magnetic source imaging
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Selected References:
- Otsubo, H; Elliott, I; Chuang, SH; Rutka, JT; Jay, V; Aung, M; Sobel, DF; Snead, OC. MEG predicts epileptic zone in lesional extrahippocampal epilepsy: 12 pediatric surgery cases. Epilepsia December 2001; 42(12):1523-30.
- Merlet, I. Dipole modeling of interictal and ictal EEG and MEG paroxysms. Epileptic Disorders, July 2001 Special Issue:11-36.
- Castillo, EM; Simos, PG; Venkataraman, V; Brier, JI; Wheless, JW; Papanicolaou, AC. Mapping of expressive language cortex using magnetic source imaging. Neurocase 2001; 7 (5): 419-22.
- Snead OC. Surgical treatment of medically refractory epilepsy in childhood. Brain Dev 2001; 23(4):199-207.
- 2003 TEC Assessment. Magnetoencephalography and magnetic source imaging: presurgical localization of epileptic lesions and presurgical functional mapping.
- Fujimoto A, Masuda H, et al. False lateralization of mesial temporal lobe epilepsy by noninvasive neurophysiological examinations. Neurol Med Chir (Tokyo). 2006 Oct;46(10):518-21.
- Okamoto H, Kakigi R,, et al. Asymmetric lateral inhibitory neural activity in the auditory system: a magnetoencephalographic study. BMC Neurosci. 2007 May 17;8:33.
- Blue Cross Blue Shield Association (BCBSA), Technology Evaluation Center (TEC). Special Report. MEG and MSI for the Purpose of Presurgical Localization of Epileptic Lesions – A Challenge for Technology Evaluation. TEC Assessment Program. Chicago, IL: BCBSA; January 2009; 23(8).Available at: http://bcbs.com/blueresources/tec/vols/23/23_08.pdf.
- American Academy of Neurology Professional Association (AANPA). Magnetoencephalography (MEG) Policy. Recommended by the AANPA Medical Economics and Management Committee. Approved by the AANPA Board of Directors on May 8, 2009. St. Paul, MN: AANPA; 2009. Available at: aan.com/globals/axon/assets/5641.pdf.
- ECRI. Magnetoencephalography and Magnetic Source Imaging for Presurgical Evaluation of Epilepsy and Brain Tumors. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 May 30. 11 p. Also available: http://www.ecri.org.
- Knowlton RC, Razdan SN, Limdi N et al. Effect of epilepsy magnetic source imaging on intracranial electrode placement. Ann Neurol 2009; 65(6):716-23.
- Smirniotopoulos JG, Wippold FJ II, Cornelius RS, Angtuaco EJ, Broderick DF, Brown DC, Creasy JL, Davis PC, Garvin CF, Holloway K, McConnell CT Jr, Mechtler LL, Rosenow JM, Seidenwurm DJ, Slavin K, Tobben PJ, Waxman AD, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® seizures and epilepsy. [online publication]. Reston (VA): American College of Radiology (ACR); 2011. 10 p.
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Policy History:
Date Reason Action
March 2011 Annual review Policy renewed
February 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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