Description of Procedure or Service

Quantitative electroencephalography (EEG) is a method of analyzing the electrical activity of the brain to derive quantitative patterns that may correspond to diagnostic information and/or cognitive deficits.

Quantitative EEG, a technique for topographic display and analysis of brain electrophysiological data, has been proposed for use in the diagnosis of various psychiatric disorders. Clinical studies have demonstrated distinctive forms of brain electrical activity in psychiatric conditions including attention deficit disorder, schizophrenia, major depression, and obsessive-compulsive disorder. However, the clinical significance of these distinctive patterns of brain wave activity is unknown. Thus the role of quantitative EEG in diagnosis, evaluation of disease progression, and treatment of these conditions has yet to be elucidated.

Regulatory Status

In 2011, the generic device Neuropsychiatric Interpretive Electroencephalograph Assessment Aid was granted a de novo 510(k) classification and cleared for marketing by the U.S. Food and Drug Administration (FDA; class II, special controls, product code: NCG). According to the FDA documentation, a neuropsychiatric interpretive EEG assessment aid is a device prescribed by a physician that uses a patient’s electroencephalogram to provide an interpretation of the patient’s neuropsychiatric condition. In addition to the general controls, approval of these devices is subject to a number of special controls, including the following:

• Clinical performance testing must demonstrate the accuracy, precision, and reproducibility of the EEG-based interpretation, including any specified equivocal ones (cutoffs).
• Clinical performance testing must demonstrate the ability of the device to function as an assessment aid for the medical condition for which the device is indicated. Performance measures must demonstrate device performance characteristics per the intended use in the intended use environment. Performance measurements must include sensitivity, specificity, positive predictive value, and negative predictive value per the device intended use. Repeatability of measurement must be demonstrated using interclass correlation coefficients and illustrated by qualitative scatterplots.
• The device design must include safeguards to prevent device use as a stand-alone diagnostic.
• The labeling must bear all information required for the safe and effective use of the device.

In 2013, the Neuropsychiatric EEG-based Assessment Aid (NEBA ; NEBA Health previously Lexicor Medical Technology) for ADHD was granted a de novo 510(k) classification and cleared for marketing by the FDA (K112711). The device is indicated to measure the theta/beta ratio of the electroencephalogram at electrode CZ on patients 6 to 17 years of age, combined with a clinician’s evaluation, to aid in the diagnosis of ADHD. NEBA should only be used by a clinician as confirmatory support for a completed clinical evaluation or as support for the clinician’s decision to pursue further testing following clinical evaluation. The device is not intended as a stand-alone tool in the evaluation or diagnosis of ADHD.

In 2017, the eVox System (Evoke Neuroscience, Inc.) was granted 510(k) classification and cleared for marketing by the FDA (K171781; FDA Product Codes: GWQ, GWJ). In 2020, the NeuralScan System was granted 510(k) classification and cleared for marketing by the FDA (K192753; FDA Product Codes: OLT, GWJ, GWQ). Both of these devices are indicated for: "the acquisition, display, and storage, of electrical activity of a patient’s brain including electroencephalograph (EEG) and event-related potentials (ERP) obtained by placing two or more electrodes on the head to aid in diagnosis." These indications are not condition- or disease-specific.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

Quantitative electroencephalographic (EEG)-based assessment of the theta/beta ratio is considered investigational. BCBSNC does not provide coverage for investigational services or procedures.

BCBSNC will provide coverage for biofeedback for the evaluation and diagnosis of attention-deficit disorder, when it is determined to be medically necessary.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this medical policy.

When Quantitative Electroencephalography is covered

Not applicable.

Biofeedback is considered medically necessary for the evaluation and diagnosis of attention-deficit disorder.

When Quantitative Electroencephalography is not covered

Quantitative electroencephalographic (EEG)-based assessment of the theta:beta ratio is considered investigational as a diagnostic aid for cognitive impairment and all mental health diagnosis, including but not limited to:

• Major depressive disorder
• Substance use disorder diagnoses
• Post-traumatic stress disorder
• Conversion disorder with seizures or convulsions
• Anxiety disorder/generalized anxiety disorder
• Postconcussional syndrome
• Autism spectrum disorders

Policy Guidelines

A report from the American Academy of Neurology and the American Clinical Neurophysiology Society concluded that quantitative EEG remains investigational for clinical use in post-concussion syndrome, mild-to-moderate head injury, learning disability, attention disorders, schizophrenia, depression, alcoholism, and drug abuse. Clinical studies have demonstrated distinctive forms of brain electrical activity in neurologic and psychiatric conditions including learning disabilities, autism, traumatic brain injury, coma, schizophrenia, major depression, and obsessive-compulsive disorder. However, the clinical significance of these distinctive patterns of brain wave activity is unknown. Thus the role of quantitative EEG in diagnosis, evaluation of disease progression, and treatment of these conditions has yet to be elucidated.

For individuals suspected of having attention-deficit/hyperactivity disorder (ADHD) who received quantitative electroencephalography (EEG), the evidence includes a number of studies on brain wave patterns, particularly the theta/beta ratio. Relevant outcomes are symptoms, functional outcomes, and medication use. Numerous studies have evaluated brain wave patterns with standard EEG equipment, and a pivotal trial, submitted to the U.S. FDA, measured the theta/beta ratio with the Neuropsychiatric EEG-based ADHD Assessment Aid system. In the pivotal trial, both the specificity and positive predictive value of quantitative EEG were high. The reclassification analysis would suggest that a negative Neuropsychiatric EEG-based ADHD Assessment Aid might make ADHD less likely, although it is not clear from this study whether the consensus diagnosis was more accurate than the initial clinical diagnosis that included patient interview and parent rating scales. The larger body of evidence also raises questions about the utility of measuring the theta/beta ratio because it has not been a consistent finding across studies. Given the uncertainty of an increase in the theta/beta ratio in patients with ADHD, additional study is needed to determine whether a low theta/beta ratio can identify children and adolescents who are unlikely to have ADHD. Also, the effect of the test on patient outcomes would allow greater certainty regarding the usefulness of this test. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals suspected of having cognitive impairment (eg, dementia) who receive quantitative electroencephalography (EEG), the evidence includes an observational study. Relevant outcomes are symptoms and functional outcomes. One study found quantitative EEG poorly diagnosed Alzheimer's disease (AD). Another study evaluating quantitative EEG for diagnosing dementia and dementia with Lewy bodies (DLB) demonstrated a sensitivity of 80% and a specificity of 89% for diagnosing dementia, and a sensitivity of 60% and a specificity of 90% for diagnosing DLB. This study had a small sample size and was conducted at a single center. There is limited evidence on the brain wave patterns that associated with cognitive impairment. Therefore, additional study is needed to determine the brain wave patterns that can identify individuals with cognitive impairment. Also, the effect of the test on patient outcomes would allow greater certainty regarding the usefulness of this test. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals suspected of having autism spectrum disorder (ASD) who receive quantitative electroencephalography (EEG), the evidence includes a systematic review and meta-analysis. Relevant outcomes are symptoms and functional outcomes. One systematic review with meta-analyses showed that autistic individuals had reduced relative alpha power (g=-0.35) and increased gamma power (absolute: g=0.37, relative: g=1.06) compared to neurotypical individuals. This systematic review did not report on sensitivity or specificity. There is limited evidence on the brain wave patterns that associated with ASD. Therefore, additional study is needed to determine the brain wave patterns that can identify individuals with ASD. Also, the effect of the test on patient outcomes would allow greater certainty regarding the usefulness of this test. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

In 2017 Wang et al. examined the aberrant EEG oscillation in major depressive patients with basal ganglia stroke with lesions in different hemispheres. Resting EEG of 16 electrodes in 58 stroke subjects, 26 of whom had post-stroke depression (PSD) (13 with left-hemisphere lesion and 13 with right-hemisphere lesion) and 32 of whom did not (18 with left lesion and 14 with right lesions), was recorded to obtain spectral power analysis for several frequency bands. Multiple analysis of variance and receiver operating characteristic (ROC) curves were used to identify differences between PSD and post-stroke non-depression (PSND), treating the different lesion hemispheres separately. Moreover, Pearson linear correlation analysis was conducted to test the severity of depressive symptoms and EEG indices. PSD with left-hemisphere lesion showed increased beta2 power in frontal and central regions, but PSD with right-hemisphere lesion showed increased theta and alpha power mainly in occipital and temporal regions. Additionally, for left-hemisphere lesions, beta2 power in central and right parietal regions provided high discrimination between PSD and PSND, and for right-hemisphere lesions, theta power was similarly discriminative in most regions, especially temporal regions. The researchers also explored the association between symptoms of depression and the power of abnormal bands but found no such relationship. The small study concluded that aberrant EEG oscillation in patients with PSD differs between patients with lesions of the left and right hemispheres, suggesting a complex association between depression and lesion location in stroke patients. The authors noted study limitations which included small study sample size which included subjects with different lesions of the basal ganglia.

Several published studies have addressed EEG brain mapping and other QEEG analysis techniques in patients with head injury. Some reports are uncontrolled, unblinded, or retrospective observations, which are difficult to use for assessing clinical utility. Patients with extensive traumatic lesions, obvious on neuroimaging studies, had EEG and QEEG abnormalities. In the one small group of patients with post-concussion syndrome, an increase in 8 to 10 Hz alpha was reported. (15) A subsequent report described reduced alpha in a much larger group of patients after mild head injury. In the latter study, mild head-injury patients were separated from controls using a bayesian statistical discriminant formula weighted toward measurements of coherence and phase relationships as well as posterior alpha and frontotemporal beta activity. The authors replicated their findings with good sensitivity and specificity. Some individuals commented that this technique is predisposed to false-positive “abnormalities" in normal subjects due to mild drowsiness or other problems. Further independent long-term studies would be beneficial to determine the effect on health outcomes.

Bong and colleagues (2020) noted that the Research Domain Criteria (RDoC) project was proposed by the National Institute of Mental Health in 2010 to create a new diagnostic system including symptoms and data from genetics, neuroscience, physiology, and self-reports.  These researchers determine the link between anxiety and executive functions via qEEG based on the RDoC system; 19-channel EEGs were recorded at the psychiatric clinic from 41 patients with symptoms of anxiety.  The EEG power spectra were analyzed.  The Executive Intelligence Test (EXIT) including the K-WAIS-IV, Stroop, controlled oral word association, and the design fluency tests were carried out.  A partial, inversed, and significant association was observed between executive intelligence quotient (EIQ) and the absolute delta power in the central region.  Similarly, a partial, inversed, and significant association was seen between design fluency and the absolute delta power in the left parietal area.  The authors concluded that the findings of this study suggested that the increase in delta power in the central region and left P3 was negatively correlated with the decrease in executive function.  It is expected that the absolute delta power plays a specific role in the task-negative default mode network in the relationship between anxiety and executive function.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

This testing would likely be reported with existing electroencephalography codes (95812, 95813, 95816,  95819) and 95957 would be reported for the analysis.

Applicable service codes for biofeedback: 90875, 90876, 90901

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. 

Scientific Background and Reference Sources

Boutros N, Fraenkel L, Feingold A. A four-step approach for developing diagnostic tests in psychiatry: EEG in ADHD as a test case. J Neuropsychiatry Clin Neurosci 2005; 17(4):455-64.

Subcommittee on Attention-Deficit/Hyperactivity Disorder Steering Committee on Quality Improvement Management, Wolraich M, Brown L et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011; 128(5):1007-22.

U.S. Food and Drug Administration. De novo classification request for Neuropsychiatric EEG-Based Assessment Aid for ADHD (NEBA) System. 2013. Available online at: http://www.accessdata.fda.gov/cdrh_docs/reviews/K112711.pdf. Last accessed January, 2014.

BCBSA Medical Policy Reference Manual [Electronic Version]. 3.01.03, 10/10/13

Specialty Matched Consultant Advisory Panel – 7/2014

BCBSA Medical Policy Reference Manual [Electronic Version]. 3.01.03, 10/9/14

Specialty Matched Consultant Advisory Panel – 7/2015

BCBSA Medical Policy Reference Manual [Electronic Version]. 3.01.03, 10/15/15

BCBSA Medical Policy Reference Manual [Electronic Version]. 3.01.03, 10/12/2017

Gloss D, Varma JK, Pringsheim T, et al. Practice advisory: The utility of EEG theta/beta power ratio in ADHD diagnosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. Nov 29 2016;87(22):2375-2379. PMID 27760867

BCBSA Medical Policy Reference Manual [Electronic Version]. 3.01.03, 10/10/2018

BCBSA Medical Policy Reference Manual [Electronic Version]. 3.01.03, 10/17/2019

Specialty Matched Consultant Advisory Panel – 6/2020

BCBSA Medical Policy Reference Manual [Electronic Version]. 3.01.03, 10/15/2020

Specialty Matched Consultant Advisory Panel – 6/2021

van Dijk H, deBeus R, Kerson C, et al. Different Spectral Analysis Methods for the Theta/Beta Ratio Calculate Different Ratios But Do Not Distinguish ADHD from Controls. Appl Psychophysiol Biofeedback. Sep 2020; 45(3): 165-173. PMID 32436141

Wolraich ML, Hagan JF, Allan C, et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. Oct 2019; 144(4). PMID 31570648

Gloss D, Varma JK, Pringsheim T, et al. Practice advisory: The utility of EEG theta/beta power ratio in ADHD diagnosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. Nov 29 2016; 87(22): 2375-2379. PMID 27760867

Specialty Matched Consultant Advisory Panel – 6/2022

Medical Director review 6/2022

Specialty Matched Consultant Advisory Panel – 6/2023

Medical Director review 6/2023

Specialty Matched Consultant Advisory Panel – 6/2024

Medical Director review 6/2024

Wang C, Chen Y, Zhang Y, et al. Quantitative EEG abnormalities in major depressive disorder with basal ganglia stroke with lesions in different hemispheres. J Affect Disord. Jun 2017; 215:172-178. PMID 28340443

Kutcher J, McCrory P, Davis G, et al. What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery? Br J Sports Med. Apr 2013; 47(5):299-303. PMID 23479488

American Academy of Neurology. Assessment: EEG brain mapping.  Report of the American Academy of Neurology, Therapeutics and Technology Assessment Subcommittee. Neurology. 1989;39(8):1100-1101.

American Psychiatric Association. Quantitative electroencephalography: A report on the present state of computerized EEG techniques.  American Psychiatric Association Task Force on Quantitative Electrophysiological Assessment. Am J Psychiatry. 1991;148(7):961-964.

Specialty Matched Consultant Advisory Panel – 6/2025

Medical Director review 6/2025

Policy Implementation/Update Information

1/28/14 New policy developed. Quantitative electroencephalographic (EEG)-based assessment is considered investigational as a diagnostic aid for neuropsychiatric disorders. Medical Director review 1/2014. (sk)

8/12/14 Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Policy statement. (sk)

2/24/15 Reference added. Policy statement changed from “Quantitative electroencephalographic (EEG)-based assessment is considered investigational as a diagnostic aid for neuropsychiatric disorders” to “Quantitative electroencephalographic (EEG)-based assessment of the theta/beta ratio is considered investigational as a diagnostic aid for attention deficit/hyperactivity disorder”. Policy non coverage statement changed from “Quantitative electroencephalographic (EEG)-based assessment that reports the strength, pattern and/or ratios of brain waves is considered investigational as a diagnostic aid for neuropsychiatric disorders, including but not limited to attention-deficit/hyperactivity disorder” to “Quantitative electroencephalographic (EEG)-based assessment of the theta:beta ratio is considered investigational as a diagnostic aid for attention deficit/hyperactivity disorder”. Intent of the Policy statement unchanged. (sk)

9/1/15 Specialty Matched Consultant Advisory Panel review 7/29/15. (sk)

12/30/15 Reference added. Codes 95816 and 95819 added to Billing/Coding section. Policy Guidelines updated. (sk)

8/30/16 Specialty Matched Consultant Advisory Panel review 7/27/2016. Policy statement unchanged. (an)

7/28/17 Specialty Matched Consultant Advisory Panel review 6/28/2017. No change to policy statement. (an)

7/27/18 Reference added. Specialty Matched Consultant Advisory Panel review 6/27/2018. No change to policy statement. (an)

7/30/19 Updated Description section and Policy Guidelines. References added. Specialty Matched Consultant Advisory Panel review 7/10/2019. (eel)

7/28/20 Removed Biofeedback policy reference from Background and Related Policies sections. References added. Specialty Matched Consultant Advisory Panel review 6/2020. No change to policy statement. (bb)

7/13/21 Biofeedback for the evaluation and diagnosis for attention-deficit disorder was added as medically necessary to the policy statement and When Covered sections. Policy Guidelines updated with 2019 AAP practice guidelines. The following CPT codes were added to the Billing/Coding section applicable to biofeedback: 90875, 90876, 90901. References added. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021. (bb/jd)

7/12/22 Updated Description section. References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement. (tt)

6/30/23 Updated Regulatory Status. References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No change to policy statement. (tt)

7/17/24 References added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. No change to policy statement. (tt)

7/16/25 Updated description, policy guidelines, and references added. Updated When Not Covered with the following: “Quantitative electroencephalographic (EEG)-based assessment of the theta:beta ratio is considered investigational as a diagnostic aid for for cognitive impairment and all mental health diagnosis, including but not limited to: Major depressive disorder; Substance use disorder diagnoses; Post-traumatic stress disorder; Conversion disorder with seizures or convulsions; Anxiety disorder/generalized anxiety disorder; Postconcussional syndrome; Autism spectrum disorders. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. Notification given 7/16/2025 for effective date 9/10/2025. (tt)