MEDICAL POLICY
POLICY TITLE
QUANTITATIVE ELECTROENCEPHALOGRAPHY AND TOPOGRAPHIC
BRAIN MAPPING
POLICY NUMBER
MP-2.037
Original Issue Date (Created):
July 1, 2002
Most Recent Review Date
(Revised):
September 25, 2007
Effective Date:
September 30, 2008- RETIRED
I.
DESCRIPTION/BACKGROUND
Quantitative electroencephalography (QEEG) is an extension of conventional
electroencephalography (EEG). QEEG involves the mathematical processing of a digitally
recorded EEG in order to highlight specific waveform components, transform the EEG into
a format or domain that elucidates relevant information, or associate numerical results with
the EEG data for subsequent review or comparison.
Topographic brain mapping (TBM) is a technique used to visually display a spatial
representation of raw EEG data. TBM, sometimes referred to as brain electrical activity
mapping (BEAM), involves the computerized analysis and topographic display of EEG
rhythms and evoked potential response on a color video screen. An assortment of maps is
created to identify patterns that differentiate pathological groups from normal ones.
II.
DEFINITIONS
EEG: Electroencephalogram is the tracing of the electrical activity of the brain by an
electroencephalograph.
EVOKED RESPONSE: is the method of testing the function of certain sense organs. A
patient who is thought to be deaf can be exposed to sound. If the hearing pathway is intact,
the electroencephalograph will record that the sound stimulus did indeed reach the brain.
III.
POLICY
Quantitative EEG may be considered medically necessary only when used as an adjunct
to, and in conjunction with, traditional EEG interpretation for the following conditions or
situations:
 Cerebrovascular disease when neuroimaging and routine EEG studies are inconclusive;
 Encephalopathy and dementia when the diagnosis remains unresolved after initial
clinical evaluation;
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MEDICAL POLICY
POLICY TITLE
QUANTITATIVE ELECTROENCEPHALOGRAPHY AND TOPOGRAPHIC
BRAIN MAPPING
POLICY NUMBER
MP-2.037
 For continuous EEG monitoring in the operating room (OR) or intensive care unit
(ICU) to detect early, acute intracranial complications and for screening for possible
epileptic seizures in high-risk ICU patients;
 Epilepsy:
 When clinical evaluation and routine EEG studies are inconclusive; or
 For topographic voltage and dipole analysis in presurgical evaluations; or
 For screening for possible epileptic spikes or seizures in long-term EEG monitoring
or ambulatory recording to facilitate subsequent expert visual EEG interpretation.
Cross-references
MP-2.302 Attention Deficit Hyperactivity Disorder
MP-2.048 Diagnostic Tests and Services
MP-2.012 Electroencephalograms
MP-4.029 Evoked Potential Studies
MP-2.030 Neurophysiological Studies (Intra-operative)
MP-2.029 Neurofeedback
IV.
EXCLUSIONS
Quantitative EEG is considered investigational, as there is insufficient evidence to support
a conclusion concerning the health outcomes or benefits associated with this procedure,
when used for the following conditions:
 Alcoholism;
 Attention deficit/hyperactivity disorders;
 Depression;
 Drug abuse;
 Learning disabilities;
 Mild or moderate head injury;
 Postconcussion syndrome;
 Schizophrenia.
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[Note: Final page is signature page and is kept on file, but not issued with Policy.]
MEDICAL POLICY
POLICY TITLE
QUANTITATIVE ELECTROENCEPHALOGRAPHY AND TOPOGRAPHIC
BRAIN MAPPING
POLICY NUMBER
MP-2.037
Topographic brain mapping is considered investigational, as there is insufficient evidence
to support a conclusion concerning the health outcomes or benefits associated with this
procedure.
V.
BENEFIT VARIATIONS
The existence of this medical policy does not mean that this service is a covered benefit
under the member's contract. Benefit determinations should be based in all cases on the
applicable contract language. Medical policies do not constitute a description of benefits.
A member’s individual or group customer benefits govern which services are covered,
which are excluded, and which are subject to benefit limits and which require
preauthorization. Members and providers should consult the member’s benefit information
or contact Capital for benefit information.
VI.
DISCLAIMER
Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute
medical advice and are subject to change. Treating providers are solely responsible for medical advice and
treatment of members. Members should discuss any medical policy related to their coverage or condition
with their provider and consult their benefit information to determine if the service is covered. If there is a
discrepancy between this medical policy and a member’s benefit information, the benefit information will
govern. Capital considers the information contained in this medical policy to be proprietary and it may only
be disseminated as permitted by law.
VII. REFERENCES
American Academy of Neurology and the American Clinical Neurophysiology Society.
Assessment of digital EEG, quantitative EEG, and EEG brain mapping. Neurology 1997;
49:277-92.
Huzzar, L. EEG in Dementia and Encephalopathy. Emedicine, May 3, 2006. [Website]:
http://www.emedicine.com/neuro/topic109.htm. Accessed July 16, 2008.
Pickett T K, Eldrup-Jorgensen J, Dillihunt R C, et al. Further experience with
computerized topographic brain mapping and selective shunting during carotid
endarterectomy. Vascular Surgery 1999; 33(1): 81-86.
Kullmann FA, Hollerbach SA, Lock GA, et al. A Brain electrical activity mapping of EEG
for the diagnosis of (sub) clinical hepatic encephalopathy in chronic liver disease.
European Journal of Gastroenterology & Hepatology 2001; 13(5): 513-522.
M. P. Jacobs GD, Fischbach MR, Davis MA. Dichter R, Dingledine DH et al. Future
directions for epilepsy research. Neurology 2001;57:1536-1542.
Nuwer MR, Hovda DA, Schrader LM, Vespa PM. Routine and quantitative EEG in mild
traumatic brain injury. Clin Neurophysiol. 2005 Jul 16.
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[Note: Final page is signature page and is kept on file, but not issued with Policy.]
MEDICAL POLICY
POLICY TITLE
QUANTITATIVE ELECTROENCEPHALOGRAPHY AND TOPOGRAPHIC
BRAIN MAPPING
POLICY NUMBER
MP-2.037
Papadelis C, Maglaveras N, Kourtidou-Papadeli C, Bamidis P, Albani M, Chatzinikolaou
K, Pappas K. Quantitative mulitchannel EEG measure predicting the optimal weaning
from ventilator in ICU patients with acute respiratory failure. Clin Neurophysiol. 2006;
117:752-70.
Reeves RR, Struve FA, Brannon GE, Pinkofsky HB. Quantitative EEG findings of a
temporal lobe abnormality not detected by magnetic resonance or SPECT imaging in a
patient with dementia. Clin EEG Neurosci. 2004 Apr; 35(2): 104-7.
Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of
epilepsy in adults. Updated03/08/07. [Website]:
http://www.sign.ac.uk/guidelines/fulltext/70/index.html Accessed July 16, 2008.
Taber’s Cyclopedic Medical Dictionary: 19th edition.
VIII. PRODUCT VARIATIONS
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] CHIP POS
[N] Indemnity
[N] PPO
[N] SpecialCare
[N] HMO
[N] POS
[N] CHIP HMO
[N] FEP HMO
[N] SeniorBlue
[N] FEP PPO
[N] SeniorBlue PPO
IX.
POLICY HISTORY
MP 2.037
CAC 9/27/05
CAC 9/26/06
CAC 9/25/07
Policy approved for retirement effective 9/30/2008.
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage
Insurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield
Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider
relations for all companies
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