Recently Released Clinical Policy Bulletin: Quantitative EEG (Brain Mapping) from Aetna
It is no surprise when insurance companies find ways to restrict what they will cover as a service for their clients, whether flood insurance liability insurance, or any other branch of this financial industry. This is especially true for medical insurance companies, which are always finding reasons to restrict payments.
This decision restricts the payment for a qEEG to be an extension of the analysis of an EEG analysis, which makes the qEEG a medical procedure requiring licensure adequate to provide credentials to do a medical EEG interpretation. If further restricts the payments to applications that match the American Academy of Neurology position paper, which approves the technique in vascular cases, encephalopathies such as dementia cases, or for epilepsy, as well as longer term EEG monitoring, where quantitative analysis allows the selection of segments for review visually, assisting the electroencephalographer in eliminating long time segments from detailed analysis.
Specifically restricted from payment are these applications:
- Asperger’s syndrome and other autism spectrum disorders
- Attention disorders
- Drug abuse
- Hypoxic ischemic encephalopathy
- Learning disability
- Mild or moderate head injury
- Panic disorder
- Post-concussion syndrome
- Predicting response to psychotropic medication
The list above is not an appropriate reason to do an EEG medically… at least not on the surface. In many of these cases the clinical decision may include ruling our an encephalopathy, a a vascular or epileptic process. As an example of this, approximately 30% of those with autism have undiscovered epileptiform discharges in the EEG, and respond well to anticonvulsants. An EEG is the only way to rule out epilepsy in such a case, and this may be allowed under the coverage listed, if the testing is ordered appropriately and the chart supports the order for the testing.
This is generally the same for TBI, where a post-traumatic vascular issue or epileptiform response to the TBI may be suspected, such as with contusion or post traumatic edema/ischemia.
In atypical clinical presentation, an alcoholic can be evaluated for dementia (Korsakov’s syndrome), as well as epilepsy (PLEDS are a common withdrawal pattern in chronic alcoholics). The chart needs to support the evaluation diagnostically for ruling out any of these covered categories.
The report can comment on medication implications, even if the testing was not done for that purpose diagnostically.
Attentional and affective disorders will not be covered, but if the physician is trying to rule out epilepsy (absence can mimic ADD) or an encephalopathy or dementia as the etiology of the psychiatric changes, then the insurance may cover the EEG and subsequent qEEG examination.
The important thing is to have the documentation in the chart to support the diagnostic/treatment question being posed with the testing.
The fact that they cover any of the qEEG at all is only due to the AAN position paper’s support for these areas. As the neuroscience is done to support more applications, then the carriers will have to amend their coverage statements. It is up to us to do the hard work to open these other areas up to payment…. and to argue for some other licenses to be covered for payment.