61567
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
36.08
Facility
$2473.67
Non-Facility
$2473.67
Documentation Required
- Documentation that non-epileptic attacks (e.g., cardiogenic syncope, psychogenic seizures) have been ruled out.
- Comprehensive presurgical evaluation documentation (inferred requirement): detailed seizure history, prior anti‑seizure medication trials and failures, seizure frequency and type.
- Electroencephalography (EEG) data including scalp EEG and, when applicable, invasive/subdural recordings — documentation of seizure focus localization (inferred from multiple EEG and invasive monitoring citations).
- Neuroimaging: high‑quality MRI with epilepsy protocol; when applicable diffusion tensor imaging (DTI), MRI thermometry for LITT, and correlation of MRI with clinical data (inferred from DTI and MRI‑guided therapy citations).
Key Coverage Criteria
- Transection of corpus callosum (callosotomy) — CPT 61541, covered if selection criteria are met
- Cerebral hemispherectomy when all selection criteria are met, including members with unilateral multi-focal epilepsy associated with infantile hemiplegia (especially in hemimegalencephaly and Sturge-Weber disease).
- Corpus callosotomy when all selection criteria are met, including members with focal to bilateral seizures (formerly known as secondarily generalized seizures).
- Temporal lobectomy (including selective amygdalohippocampectomy) when all selection criteria are met, including members with focal impaired awareness seizures (formerly known as complex partial seizures) of temporal or extra-temporal origin.
- Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) (e.g., NeuroBlate, Visualase) as an alternative to standard surgery where criteria in section A. on epilepsy surgery are met.
- Deep brain stimulation for members with intractable seizures when medical necessity criteria are met as specified in CPB 0208 - Deep Brain Stimulation.
1 Active Policy
AETNA-CPB-0394 — Epilepsy Surgery
Related Codes
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