FCA Preauth for Video EEG

1. FCA Preauth for Video EEG Suggestions Allen Okie MD FACAI, FAAP

2. FCA Pre-Authorization for Video EEG • All of the InterQual Standards Plus • Ambulatory EEG • Failed response to two concurrent anti-epileptic drug therapy • AHCA does not pay for a 2nd Video EEG • Recommendations for FCA Admission Policy • 1-2 day observation • Each additional day for inpatient must meet criteria through FCA Pre-Auth

3. Cost Consideration Video EEG Inpatient outpatient

4. Video EEG Recommendations • Home Application with Video Conference monitoring and Remote Patient Monitoring • Develop Neurology department 3-4 beds – not inpatient with RPM or with Home Care Nursing

5. V-EEG Video • V-EEG involves video recording a patient while simultaneously recording their EEG, usually over a period of some days. This allows correlation of a video-recorded seizure with any abnormal electrical discharge in the brain, demonstrating an epileptic or non-epileptic basis for the seizure. V-EEG is most often used to clarify an epileptic diagnosis, to differentiate between epilepsy and non-epileptic seizures, or for detailed presurgical evaluation for intractable epilepsy. The technique may be especially useful in children who cannot always adequately describe the subjective symptoms used by the clinician to differentiate seizure types. A member will have scalp electrodes connected to a lightweight box that can be worn while moving around and ultimately this box transmits the EEG recordings to a computer network via either wireless or cable systems. The computer systems can have inbuilt seizure detection software, and staff or family members can also press an event button to indicate a seizure, to facilitate comparison of the video with EEG trace. Various means are often employed to increase the chances of observing a seizure during the V-EEG recording, including withdrawing anticonvulsant medication, sleep deprivation, or saline injections in cases of suspected psychologic seizures. Inpatient procedures allow for more data collection and direct medical supervision.

6. Video EEG

7. Video EEG This is invasive and usually only performed for localized foci of seizure for possible surgery

8. Video EEG

9. Out Patient Video EEG This is the Professional Societies Position

10. A-EEG Ambulatory EEG • Ambulatory cassette EEG monitoring was developed as an extension of the routine EEG examination. The member maintains a normal routine, while wearing a monitoring system. A portable cassette recorder is used to continuously record brain wave patterns. This method allows the clinician to observe the member's EEG activity in multiple states, such as sleeping, waking and normal daily activities. The member or caregiver uses a button to mark the recording in order to indicate when an event occurred. The information provided may allow the clinician to identify the seizure type. This method may also provide reliable data for evaluating patients with suspected non-epileptic events, such as syncope, transient ischemic attacks, pseudoseizures and poorly defined seizure disorders.

11. Duration of Service Wellcare • The goal length of stay for V-EEG would be 23 hour observation. However, the event being monitored may not occur in this time frame. Admission may be necessary for further monitoring or for preoperative localization of seizure foci. The length of stay is assigned per day, based on clinical review, up to four days. Inpatient stay beyond four days requires medical review. A-EEG is done on an outpatient basis.

12. POSITION STATEMENT Wellcare • Video Electroencephalography (V-EEG) is considered medically necessary in the following circumstances: • 1) May be authorized for inpatient admission: •  To localize the seizure focus in members with documented medically refractory seizures prior to possible resective epilepsy surgery or intracranial electrode implantation and surgery • 2) May be authorized for initial 23 - 48 hour observation: •  For members with a diagnosis of known seizure history with increasing symptoms; OR, •  For members who are admitted to see if they are seizure-free prior to withdrawal from anti-epileptic

13. AETNA • Aetna considers electroencephalographic (EEG) video monitoring medically necessary for the following indications, where the diagnosis can not be made by neurological examination, standard EEG studies, and ambulatory EEG monitoring, and non-neurological causes of symptoms (e.g., syncope, cardiac arrhythmias) have been ruled out: • To differentiate epileptic events from psychogenic seizures; or • To establish the first diagnosis of a seizure disorder; or • To establish the specific type of epilepsy in poorly characterized seizure types where such characterization is medically necessary to select the most appropriate therapeutic regimen. • In addition, upon individual case review, EEG video monitoring may be considered medically necessary to establish the diagnosis of epilepsy in very young children with clinical symptoms consistent with epilepsy, and abnormal routine EEG consistent with epilepsy. • Note: Once the cause of seizures and specific type of epilepsy has been established, continued video EEG monitoring (e.g., for monitoring response to therapy or titrating medication dosages) is considered not medically necessary.  In these cases, response to therapy can be assessed using standard EEG monitoring or ambulatory EEG monitoring.

14. Aetna Video EEG • Aetna considers EEG video monitoring medically necessary for identification and localization of a seizure focus in persons with intractable epilepsy who are being considered for surgery.  See also CPB 0394 - Epilepsy Surgery. • Aetna considers EEG video monitoring experimental and investigational for all other indications (e.g., assessment of the effectiveness of drug treatment in epilepsies, and prognosis of (i) cardiac arrest treated with hypothermia, and (ii) newborns with hypoxic-ischemic encephalopathy treated with hypothermia; not an all inclusive list) because its effectiveness for these indications has not been established • The medically necessary level of care a member requires should be addressed individually according to the member's clinical needs. An acute level of care is not considered medically necessary for (m)any persons requiring video EEG monitoring. • (my parenthesis)

15. Aetna Video EEG • Video EEG has a role subsequent to a new diagnosis if the diagnosis is or becomes uncertain or if surgery is considered" (Ross et al, 2001). • The role of video and ambulatory EEG is confined to refining or changing an uncertain diagnosis or in preoperative evaluations for seizure surgery (Ross et al, 2001). When seizures are frequent and features are atypical or uncertain, these EEGs may well contribute information necessary to correct a misdiagnosis. The literature describing these EEGs appears confined to specialists in academic centers. • [t]he literature suggests that ambulatory and video EEGs are useful in a first diagnosis if standard EEG, CT, and MRI are non-diagnostic. Video EEGs are also useful in diagnosis in very young children, in patients with poorly characterized seizure types, and in those with suspected psychogenic seizures, especially if episodes are frequent

16. Wake Forest • The Wake Forest Baptist Health Epilepsy Monitoring Unit (EMU) provides diagnosis and evaluations for people with suspected epilepsy. While this dedicated six-bed unit is an inpatient facility, outpatient monitoring is also available. We also provide neurointensive monitoring in the intensive care unit (ICU) and Video-Electroencephalograph (EEG) monitoring services.

17. Home VideoEEG • Home EEG and video monitoring in epilepsy: first experiences. • Beun AM, Gutter T, Overweg J. • Author information • Abstract • In an out-patient epilepsy clinic methods were developed for mobile epilepsy diagnosis and treatment. One of the diagnostic facilities is long-term EEG/video monitoring at home. Method and first results are presented together with a case report of an 8-year-old boy with persistent seizures. • Corresponding author. Tel.: (023) 237577; Fax: (023) 281002.

18. Video-EEG Monitoring Video-EEG recordings can be done on hospitalized inpatients or on outpatients, though the inpatient recording typically is of better quality as technologists are available to adjust electrodes and diminish outside activity that can interfere with the recording. - See more at: http://epilepsy.med.nyu.edu/diagnosis-treatment/eeg/video-eeg-monitoring.

19. ADVANCED MEDICAL ELECTRONICS CORPORATIONADVANCED MEDICAL ELECTRONICS CORPORATION 6901 E FISH LAKE RD, STE 190 MAPLE GROVE, MN - DESCRIPTION (provided by applicant): This project will develop an advanced wireless home video electroencephalograph (EEG) system based on an ultra-miniature ambulatory EEG recorder combined with new synchronized wireless high-quality video recording techn ology. An initial diagnosis of epilepsy is often based on the description of a seizure, a neurological examination, and routine EEG studies. However, the cause of a seizure may still be unclear and longer term EEG monitoring can be used to confirm the diagnosis in both children and adults. Ambulatory EEG recorders are often used in these long term studies allowing a patient to go home with the recorder attached and continuously monitoring seizure activity. With currently available ambulatory EEG recorders, the size of the recorder and non-existent or limited video recording capability diminishes the benefits of ambulatory EEG. Video monitoring can play an integral role in the diagnosis of epilepsy. Recordings from the brain along with video recordings allow physicians to document and analyze patients' seizures. Video scalp electroencephalography (v-EEG) is a cornerstone technology for the evaluation of patients presenting with transient, paroxysmal clinical events associated with neurological symptoms. Ambula tory EEG recorders have existed for years and in the past decade they have been reduced in size and included limited video recording. However, the size of even the most advanced products remains an obstacle, particularly for small children, making home monitoring difficult. Ambulatory video monitoring is limited to a single tethered camera, if available. The recent widespread commercialization of several enabling technologies makes possible the creation of a miniature ambulatory EEG recorder with synchronized video approximately one-tenth the size of currently available systems. The proposed advanced ambulatory v-EEG will be developed and evaluated against a gold-standard clinical v-EEG system at the Mayo clinic. PUBLIC HEALTH RELEVANCE: One of the most common neurological diseases is epilepsy. Epilepsy refers to the tendency to have unprovoked seizures, and encompasses a number of different syndromes. It has a prevalence of 0.5 to one percent. This translates to approximately two million persons in th e United States. Expensive long term hospital stays for diagnostic video scalp electroencephalography (v-EEG) monitoring are typically prescribed. Ambulatory v-EEG carried out in the patient home can provide a large cost savings and patient benefit if size , ease of use, and adequate video issues can be resolved.