BlueCross and BlueShield of Montana Medical Policy/Codes
Topographic Brain Mapping
Chapter: Medicine: Tests
Current Effective Date: February 01, 2014
Original Effective Date: September 24, 2013
Publish Date: January 15, 2014
Revised Dates: January 15, 2014
Description

Topographic Brain Mapping (TBM), also known as quantitative electroencephalogram (QEEG), or brain electrical activity mapping (BEAM), is a visual enhancement of a traditional surface electroencephalogram (EEG). The enhancement process transforms the surface EEG data into a pictorial mapping (i.e., topographic image) of the seizure activity. Enhanced images are then placed on a schematic map of the brain, and the activity data is algorithmically analyzed by the size of the activity spike, the frequency of the discharges and the locality of the spikes. These algorithmic data are then compared to a database of normal patient brainwave activity to determine specific seizure types, focal location of seizure activity, or possible underlying medical conditions.

Policy

Each benefit plan, summary plan description, or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description, or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description, or contract will govern.

Coverage

Topographic brain mapping (TBM), brain electrical activity mapping (BEAM), and quantitative electroencephalogram (QEEG), may be considered medical necessary when used as an adjunct to traditional electroencephalogram (EEG) and/or diagnostic evaluation of epilepsy when any one of the following criteria is met:

  • The surface or long-term EEG is inconclusive and additional testing for possible epileptic spikes or seizures is needed; OR
  • Ambulatory recording is needed to facilitate subsequent visual EEG interpretation; OR
  • There is need for topographic voltage and dipole analysis in pre-surgical candidates with intractable epilepsy:
    1. As continuous monitoring in the operating room for the early detection of an acute intracranial complication during cerebrovascular surgery (i.e., intracranial, carotid endarterectomy); OR
    2. As monitoring for the detection of nonconvulsive seizures in high risk patients in the intensive care unit and operating room.  

NOTE: It is recommended that TBM be administered and reviewed by physicians highly skilled in clinical TBM interpretation. 

Topographic brain mapping (TBM) is considered experimental, investigational, and/or unproven for all other indications* including but not limited to:

  • Post-concussion syndrome
  • Mild or moderate head injury
  • Learning disability
  • Attention disorders
  • Schizophrenia
  • Depression
  • Alcoholism
  • Drug abuse
  • Tinnitus
  • Predicting response to psychotrophic medication.

Rationale

Topographic brain mapping (TBM), also known as brain electrical activity mapping (BEAM), or quantitative electroencephalogram (QEEG), is a technique for topographic display and analysis of brain electrophysiological data proposed for use in the diagnosis of various conditions. Clinical studies have demonstrated distinctive forms of brain electrical activity in psychiatric conditions including attention deficit disorder (ADD), schizophrenia, major depression, and obsessive-compulsive disorder (OCD). However, the clinical significance of these distinctive patterns of brain wave activity is unknown. Thus the role of QEEG in diagnosis, evaluation of disease progression, and treatment of these conditions has yet to be elucidated. A report from the American Academy of Neurology (AAN) concluded that QEEG remains experimental, investigational and /or unproven for clinical use in post-concussion syndrome, mild-to-moderate head injury, learning disability, attention disorders, schizophrenia, depression, alcoholism, and drug abuse.(1)

Crumbley and Associates (2005) examined the use of QEEG in predicting response to psychotropic medications. The clinical outcomes of two groups of patients were compared to those with prescribed medication regimens that were concordant with the quantitative EEG predictors, and those whose medication regimens were discordant with the QEEG predictors. Participants included 70 inpatient adolescents who were administered QEEG upon admission. The results indicated no significant difference in clinical outcome between the two groups. The failure of this study to find significant differences in patient outcomes questions the efficacy of QEEG. (2)

Chabot et al. conducted a literature review to determine the efficacy of using TBM in children and adolescent psychiatric disorders. Most of the studies focused on children and adolescents with attention or learning problems. The researchers found other possible uses of TBM in determining appropriate medication selection, following treatment response, and delineating the underlying cause of specific psychiatric disorders, however, most of this data was obtained from specialized research documents. The authors also concluded that TBM may prove to be a valuable imaging technique that could be used in children with attention and learning problems. They suggested that TBM may be beneficial in differentiating between Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) and Learning Disorder (LD), and may be useful in optimizing pharmacological treatment, remediation, or psychological interventions. The overall body of scientific evidence however, is of insufficient quantity and quality to support the use of TBM for these indications. (3)

The application of brain mapping is discussed in numerous textbooks and incorporated in several practice parameters in relation to the diagnosis of patients with epilepsy, the quantitative monitoring of patients during cranial surgery, or when monitoring high-risk patients in an ICU. TBM is a useful adjunct to a surface EEG and provides additional detail that can confirm the diagnosis of seizure-like activity, when performed and analyzed by a specially trained diagnostician.

There is insufficient evidence in the published, peer reviewed, scientific literature to support the use of TBM for:

  • Alcoholism
  • Attention-deficit/hyperactivity disorder
  • Depression
  • Drug/substance abuse
  • Mild or moderate head injury
  • Learning disability
  • Schizophrenia

The use of TBM in these clinical situations is not recognized by the American Academy of Neurology (AAN). (1)

2014 Update

A search of peer reviewed literature through September 2013 identified additional clinical trial publications for various medical and psychiatric conditions. No additional published studies were identified that would prompt reconsideration of the policy statement, which remains unchanged. Supplemental studies were added to support the current coverage position.

In 2007, Ashton et al. studied high frequency localized "hot spots" in temporal lobes of patients with intractable tinnitus. Tinnitus, which is the perception of noise in the absence of an external auditory stimulus, is associated with a number of conditions. Brain imaging studies indicate increased neuronal excitability and decreased density of benzodiazepine receptors in temporal (auditory) cortex but the source and mechanism of such changes are unknown. Various EEG abnormalities involving temporal lobe and other brain areas have been described but recordings have been limited to standard EEG wave bands up to frequencies of 22Hz. This clinical study of otherwise healthy patients with intractable unilateral tinnitus, using QEEG,  identified discrete localized unilateral foci of high frequency activity in the gamma range (>40-80Hz) over the auditory cortex in eight patients experiencing tinnitus during recording. These high frequency "hot spots" were not present in 25 subjects without tinnitus. The results suggest that further EEG investigations should include recordings in the gamma frequency range since such high frequency oscillations are believed to be necessary for perception. Identification of "hot spots" in tinnitus patients would provide a means for monitoring the effects of new treatments. These findings may also provide a model for exploration of more complex phenomena such as verbal and musical hallucinations. (4)

Additional studies were examined that included patients with cerebrovascular conditions, hypoxic ischemic encephalopathy, ischemic stroke, subarachnoid hemorrhage, the   impact on functional status and the prognostic value of QEEG. Each study ranged from 5-110 patients per study. Most studies indicate there may be a future benefit to QEEG testing in patients with neurovascular conditions but recommended additional studies with larger samples. (5). 

Professional organizations:

The American Academy of Neurology (AAN) created clinical guidelines in 1997 which were reaffirmed in 2006 and 2009. Currently, QEEG's clinical usefulness is limited but it has substantial potential for future applications. Techniques used in QEEG vary substantially, causing “abnormalities” resulting in potential misdiagnosis; therefore EEG brain mapping and other advanced QEEG techniques should be used only by physicians highly skilled in clinical EEG, and only as an adjunct to and in conjunction with traditional EEG interpretation. QEEG techniques are considered established as an addition to digital EEG in epilepsy for potential epileptic seizures in high-risk intensive care patients and in the operating room for continuous EEG monitoring by frequency-trending to detect early, acute intracranial complication and for screening.

Certain QEEG techniques are considered as possibly useful as a practice option, in addition to digital EEG in epilepsy for topographic voltage and dipole analysis in presurgical evaluations. QEEG may possibly be useful in evaluating certain patients with symptoms of cerebrovascular disease whose neuroimaging and routine EEG studies are not conclusive. For most patients, computerized axial tomography (CT) and magnetic resonance imaging (MRI) remains the test of choice for patients with cerebrovascular disease. QEEG has no clear medical indication in the evaluation of patients with cerebrovascular disease when MRI, CT, and routine EEG are available. On the basis of current clinical literature, opinions of most experts, and proposed rationales for their use, QEEG remains experimental, investigational, and/or unproven for clinical use in postconcussion syndrome, mild or moderate head injury, learning disability, attention disorders, schizophrenia, depression, alcoholism, and drug abuse (1).

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

ICD-10 Codes
00K00ZZ, 00K03ZZ, 00K04ZZ, 00K70ZZ, 00K73ZZ, 00K74ZZ, 00K80ZZ, 00K83ZZ, 00K84ZZ, 00K90ZZ, 00K93ZZ, 00K94ZZ, 00KA0ZZ, 00KA4ZZ, 00KA4ZZ, 00KB0ZZ, 00KB3ZZ, 00KB4ZZ, 00KC0ZZ, 00KC3ZZ, 00KC4ZZ, ,00KD0ZZ, 00KD3ZZ, 00KD4ZZ
Procedural Codes: S8040
References
  1. American Academy of Neurology (AAN). Assessment of Digital EEG, Quantitative EEG and EEG Brain Mapping, July 1997 (reaffirmed 10/17/2003, 12/9/2006): 5, 9: www.acns.org (Accessed October 4, 2013).
  2. Crumbley, J.A. et al. The Neurometric-Quantitative Electroencephalogram as a Predictor for Psychopharmacological Treatment: An Investigation of Clinical Utility. Journal of Experimental Neuropsychology (2005) 27(6): 769-778.
  3. Chabot, R.J., Michele, F. et al. The Role of Quantitative Electroencephalography in Child and Adolescent Psychiatric Disorders. Child and Adolescent Psychiatric Clinics of North America.
  4. Ashton, H, et al. High Frequency Localizsed “Hot Spots” in Temporal Lobes of Patients with Intractable Tinnitus: A Quantitative Electroencephalographic (QEEG) Study, University of Newcastle, United Kingdom, 2007 Oct 9:426(1):23-8. Epub, Aug 22, 2007. www.nih.gov (Accessed October 17, 2013).
  5. Quantitative Electroencephalography for Mapping Nonpsychiatric Conditions. Health Technology Assessment Information Service (2012 July):1-12. www.ecri.org . (Accessed 10/14/2013).
  6. Quantitative Electroencephalography for Mapping Psychiatric Conditions. Health Technology Assessment Information Service (2012 July):1-10. <www.ecri.org>. (Accessed October 14, 2013).
  7. Engel, J., Burchfiel, J, et al. Long Term Monitoring for Epilepsy. Electroencephalography and Clinical Neurophysiology (1993) 87: 437-458.
  8. Guideline Six: Recommendation for Telephone Transmission of EEG's. Journal of Clinical Neurophysiology. American Electroencephalographic Society (1994) 11: 28-29.
  9. Nuwer, M. Assessment of digital EEG, quantitative EEG, and EEG brain mapping: report of the Bigler, Ed., Lajiness-O'Neill, R.., et al. Technology in the assessment of learning disability. Journal of Learning Disability (1998 January-February) 31(1):67-82.
  10. Matsuzaka, T., Ono K., et al. Quantitative EEG analyses and surgical outcome after corpus callosotomy. Epilepsia (1999 September) 40(9):1269-1278.
  11. Holschneider, D.P., Leuchter, A.F., et al. Clinical neurophysiology using electroencephalography in geriatric psychiatry: neurobiologic implications and clinical utility. Journal of Geriatric Psychiatry Neurology (1999 fall) 12(3): 150-164.
  12. Drake, M.E., Padamadan, H, et al. Interictal quantitative EEG in epilepsy. Seizure (1998 February) 7(1): 39-42.
  13. Claus, J.J., Kwa, V.I., et al. Slowing on quantitative spectral EEG is a marker for rate of subsequent cognitive and functional decline in early Alzheimer disease. Alzheimer Disease Association Disorder (1998 September) 12(3): 167-174.
  14. Ricker, J.H., Zafonte, R.D., et al. Functional Neuroimaging and Quantitative Electroencephalography in Adult Traumatic Head Injury: Clinical Applications and Interpretive Cautions. Journal of Head Trauma Rehabilitation (2000 April) 15(2): 859-868.
  15. Wallace, B.E., Wagner, A.K., et al. A History and Review of Quantitative Electroencephalography in Traumatic Brain Injury. Journal of Head Trauma Rehabilitation (2001 April) 16(2): 165-190.
  16. Procaccio, F., Polo, A., et al. Electrophysiologic monitoring in neurointensive care. Current Opinion in Critical Care (2001 April) 7(2): 74-80.
  17. Electroencephalograms (EEGs)-Archived. Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2002 April 15) Medicine 2.01.14.
  18. The Merck Manual Diagnostic Procedures, Section 6, Chapter 77. Diagnosis of Brain, Spinal Cord, and Nerve Disorders. Second Home Edition. (2003 April) web site accessed 6/16/2003.
  19. Topographic Brain Mapping - Archived. Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 March) Medicine: 2.01.10
  20. Electroencephalograms (EEGs) - Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2004 January) Medicine: 2.01.14.
  21. Nuwer, M.R., Hovda, D.A., et al. Routine and quantitative EEG in mild traumatic brain injury. Clinical Neurophysiology (2005) 116(9): 2001-2025.
  22. Fingelkurts, A.A., Kaplan, A.Y., et al. Interictal EEG as a physiological adaptation. Part II. Topographic variability of composition of brain oscillations in interictal EEG. Clinical Neurophysiology (2006 April) 117(4): 789-802.
History
June 2013  New 2013 BCBSMT medical policy.
February 2014 Policy revised with literature review; ICD codes updated. Coverage unchanged.
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Topographic Brain Mapping