CG-SURG-91 Minimally Invasive Ablative Procedures for Epilepsy

This policy addresses minimally invasive ablative procedures for epilepsy, specifically MRI-guided laser interstitial thermal ablation (MRIgLITT, including stereotactic laser amygdalohippocampotomy) and stereotactic radiofrequency thermocoagulation (RF‑TC). MRIgLITT is medically necessary only when disabling seizures persist despite two or more tolerated antiepileptic drug regimens and there are two or fewer well-delineated epileptogenic foci accessible by laser; RF‑TC is medically necessary for hypothalamic hamartomas. Stereotactic laser techniques when these criteria are not met, RF‑TC for other indications, and other minimally invasive procedures (e.g., stereotactic RF amygdalohippocampectomy, sEEG‑guided RF thermocoagulation, or stereotactic cryosurgery) are not medically necessary.

"The treatment of medically refractory epilepsy using stereotactic laser techniques (MRI-guided laser interstitial thermal ablation [MRIgLITT]), including stereotactic laser amygdalohippocampotomy (..."