Medical Policy Magnetoencephalography/ Magnetic Source Imaging Table of Contents • Policy: Commercial • Coding Information • Information Pertaining to All Policies • Policy: Medicare • Description • References • Authorization Information • Policy History Policy Number: 137 BCBSA Reference Number: 6.01.21 NCD/LCD: N/A Related Policies None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO BlueSM and Medicare PPO BlueSM Members Magnetoencephalography/magnetic source imaging may be MEDICALLY NECESSARY in the following conditions: • Determining the laterality of language function, as a substitute for the Wada test, in patients being prepared for surgery for epilepsy, brain tumors, and other indications requiring brain resection, or • As part of the preoperative evaluation of patients with intractable epilepsy (defined as seizures refractory to at least two first-line anticonvulsants) when standard techniques, such as MRI and EEG, do not provide satisfactory localization of epileptic lesion(s). Magnetoencephalography/magnetic source imaging is INVESTIGATIONAL for all other conditions. Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient. Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient. Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. The following codes are included below for informational purposes only; this is not an all-inclusive list. The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes: Code Description 95965 Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (e.g., epileptic cerebral cortex localization) 95966 Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization) 95967 Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (e.g., sensory, motor, language, or visual cortex localization) HCPCS Codes HCPCS codes: Code Description S8035 Magnetic source imaging The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT/HCPCS codes above if medical necessity criteria are met: ICD-10 Diagnosis Codes ICD-10-CM diagnosis codes:Code Description C71.0 Malignant Neoplasm Of Cerebrum, Except Lobes And Ventricles C71.1 Malignant Neoplasm Of Frontal Lobe C71.2 Malignant Neoplasm Of Temporal Lobe C71.3 Malignant Neoplasm Of Parietal Lobe C71.4 Malignant Neoplasm Of Occipital Lobe C71.5 Malignant Neoplasm Of Cerebral Ventricle C71.6 Malignant Neoplasm Of Cerebellum C71.7 Malignant Neoplasm Of Brain Stem C71.8 Malignant Neoplasm Of Overlapping Sites Of Brain C71.9 Malignant Neoplasm Of Brain, Unspecified C79.31 Secondary Malignant Neoplasm Of Brain D09.8 Carcinoma in situ of other specified sites D33.0 Benign Neoplasm Of Brain, Supratentorial D33.1 Benign Neoplasm Of Brain, Infratentorial D33.2 Benign Neoplasm Of Brain, Unspecified D43.0 Neoplasm Of Uncertain Behavior Of Brain, Supratentorial D43.1 Neoplasm Of Uncertain Behavior Of Brain, Infratentorial D43.2 Neoplasm Of Uncertain Behavior Of Brain, Unspecified D49.6 Neoplasm Of Unspecified Behavior Of Brain Localization-Related (Focal) (Partial) Idiopathic Epilepsy And Epileptic Syndromes With G40.001 Seizures Of Localized Onset, Not Intractable, With Status Epilepticus Localization-Related (Focal) (Partial) Idiopathic Epilepsy And Epileptic Syndromes With G40.009 Seizures Of Localized Onset, Not Intractable, Without Status Epilepticus Localization-Related (Focal) (Partial) Idiopathic Epilepsy And Epileptic Syndromes With G40.019 Seizures Of Localized Onset, Intractable, Without Status Epilepticus Localization-Related (Focal) (Partial) Symptomatic Epilepsy And Epileptic Syndromes G40.101 With Simple Partial Seizures, Not Intractable, With Status Epilepticus Localization-Related (Focal) (Partial) Symptomatic Epilepsy And Epileptic Syndromes G40.109 With Simple Partial Seizures, Not Intractable, Without Status Epilepticus Localization-Related (Focal) (Partial) Symptomatic Epilepsy And Epileptic Syndromes G40.111 With Simple Partial Seizures, Intractable, With Status Epilepticus Localization-Related (Focal) (Partial) Symptomatic Epilepsy And Epileptic Syndromes G40.119 With Simple Partial Seizures, Intractable, Without Status Epilepticus Localization-Related (Focal) (Partial) Symptomatic Epilepsy And Epileptic Syndromes G40.201 With Complex Partial Seizures, Not Intractable, With Status Epilepticus Localization-Related (Focal) (Partial) Symptomatic Epilepsy And Epileptic Syndromes G40.209 With Complex Partial Seizures, Not Intractable, Without Status Epilepticus Localization-Related (Focal) (Partial) Symptomatic Epilepsy And Epileptic Syndromes G40.211 With Complex Partial Seizures, Intractable, With Status Epilepticus Localization-Related (Focal) (Partial) Symptomatic Epilepsy And Epileptic Syndromes G40.219 With Complex Partial Seizures, Intractable, Without Status Epilepticus Generalized Idiopathic Epilepsy And Epileptic Syndromes, Not Intractable, With Status G40.301 Epilepticus Generalized Idiopathic Epilepsy And Epileptic Syndromes, Not Intractable, Without G40.309 Status Epilepticus Generalized Idiopathic Epilepsy And Epileptic Syndromes, Intractable, With Status G40.311 Epilepticus Generalized Idiopathic Epilepsy And Epileptic Syndromes, Intractable, Without Status G40.319 Epilepticus Other Generalized Epilepsy And Epileptic Syndromes, Not Intractable, With Status G40.401 Epilepticus Other Generalized Epilepsy And Epileptic Syndromes, Not Intractable, Without Status G40.409 Epilepticus Other Generalized Epilepsy And Epileptic Syndromes, Intractable, With Status G40.411 Epilepticus Other Generalized Epilepsy And Epileptic Syndromes, Intractable, Without Status G40.419 Epilepticus G40.42 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder G40.501 Epileptic Seizures Related To External Causes, Not Intractable, With Status Epilepticus Epileptic Seizures Related To External Causes, Not Intractable, Without Status G40.509 Epilepticus G40.801 Other Epilepsy, Not Intractable, With Status Epilepticus G40.802 Other Epilepsy, Not Intractable, Without Status Epilepticus G40.803 Other Epilepsy, Intractable, With Status Epilepticus G40.804 Other Epilepsy, Intractable, Without Status Epilepticus G40.811 Lennox-Gastaut Syndrome, Not Intractable, With Status Epilepticus G40.812 Lennox-Gastaut Syndrome, Not Intractable, Without Status Epilepticus G40.813 Lennox-Gastaut Syndrome, Intractable, With Status Epilepticus G40.814 Lennox-Gastaut Syndrome, Intractable, Without Status Epilepticus G40.821 Epileptic Spasms, Not Intractable, With Status Epilepticus G40.822 Epileptic Spasms, Not Intractable, Without Status Epilepticus G40.823 Epileptic Spasms, Intractable, With Status Epilepticus G40.824 Epileptic Spasms, Intractable, Without Status Epilepticus G40.833 Dravet syndrome, intractable, with status epilepticus G40.834 Dravet syndrome, intractable, without status epilepticus G40.89 Other Seizures G40.901 Epilepsy, Unspecified, Not Intractable, With Status Epilepticus G40.909 Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus G40.911 Epilepsy, Unspecified, Intractable, With Status Epilepticus G40.919 Epilepsy, Unspecified, Intractable, Without Status Epilepticus G40.A01 Absence Epileptic Syndrome, Not Intractable, With Status Epilepticus G40.A09 Absence Epileptic Syndrome, Not Intractable, Without Status Epilepticus G40.A11 Absence Epileptic Syndrome, Intractable, With Status Epilepticus G40.A19 Absence Epileptic Syndrome, Intractable, Without Status Epilepticus G40.B01 Juvenile Myoclonic Epilepsy, Not Intractable, With Status Epilepticus G40.B09 Juvenile Myoclonic Epilepsy, Not Intractable, Without Status Epilepticus G40.B11 Juvenile Myoclonic Epilepsy, Intractable, With Status Epilepticus G40.B19 Juvenile Myoclonic Epilepsy, Intractable, Without Status Epilepticus Nontraumatic Subarachnoid Hemorrhage From Unspecified Carotid Siphon And I60.00 Bifurcation I60.01 Nontraumatic Subarachnoid Hemorrhage From Right Carotid Siphon And Bifurcation I60.02 Nontraumatic Subarachnoid Hemorrhage From Left Carotid Siphon And Bifurcation I60.10 Nontraumatic Subarachnoid Hemorrhage From Unspecified Middle Cerebral Artery I60.11 Nontraumatic Subarachnoid Hemorrhage From Right Middle Cerebral Artery I60.12 Nontraumatic Subarachnoid Hemorrhage From Left Middle Cerebral Artery Nontraumatic Subarachnoid Hemorrhage From Unspecified Posterior Communicating I60.30 Artery I60.31