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National Medical Policy


Quantitative Electroencephalography (QEEG)

Policy Number:


Effective Date*: October 2013


October 2014
This National Medical Policy is subject to the terms in the
at the end of this document

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Article (Local)*
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QEEG Oct 14

Current Policy Statement

Health Net Inc, considers quantitative electroencephalography (QEEG), also referred
to as brain mapping, medically necessary, as an adjunct to traditional EEG for any of
the following:

For ambulatory recording, to facilitate subsequent expert visual EEG

interpretation; or


For screening for possible spikes or seizures in long-term EEG monitoring; or


For topographic voltage and dipole analysis in pre-surgical evaluations in

candidates for epilepsy surgery; or


Evaluation of certain patients with symptoms of cerebrovascular disease whose

neuroimaging and routine EEG studies are not conclusive (e.g., patients in
whom the neuroimaging tests are nonlocalizing, but substantial clinical suspicion
of focal cerebral dysfunction remains; patients who have additional clinical
problems or complications such as coma or possible seizures); or


For continuous EEG monitoring by frequency trending in the OR or ICU to detect

early acute intracranial complications; or


For screening for possible epileptic seizures in high-risk ICU patients; or


Evaluation of individuals with dementia or encephalopathy whose neuroimaging

and routine EEG studies are inconclusive

Health Net Inc considers quantitative EEG (brain mapping) investigational for the
following indications, due to lack of evidence in the peer review literature
demonstrating its effectiveness:

Attention disorders
Drug Abuse
Learning disability
Migraine headache
Minor or moderate head injury
Parkinson Disease
Postconcussion syndrome


Quantitative electroencephalography
Alzheimer's disease
Steady-state visual-evoked potentials
Parkinson disease
Subcortical vascular dementia

Codes Related To This Policy


QEEG Oct 14

The codes listed in this policy are for reference purposes only. Listing of a code in
this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and
medical necessity criteria. This list of codes may not be all inclusive.
On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and
inpatient procedures will be replaced by ICD-10 code sets. Health Net National
Medical Policies will now include the preliminary ICD-10 codes in preparation for this
transition. Please note that these may not be the final versions of the codes and
that will not be accepted for billing or payment purposes until the October 1, 2015
implementation date.

ICD-9 Codes

Dementia in conditions classified elsewhere without behavioral
Dementia in conditions classified elsewhere with behavioral
Dementia , unspecified
Epilepsy and recurrent seizures
Encephalopathy, not elsewhere classified
Toxic encephalopathy
Post traumatic seizures
Other convulsions

ICD-10 Codes

Dementia in other diseases classified elsewhere without

behavioral disturbance
Dementia in other diseases classified elsewhere with
behavioral disturbance
Unspecified dementia without behavioral disturbance
Unspecified dementia with behavioral disturbance
Psychotic disorder with hallucinations due to known
physiological condition
Other specified mental disorders due to known physiological
Epilepsy and recurrent seizures
Toxic encephalopathy
Other and unspecified encephalopathy
Post traumatic seizures
Unspecified convulsions

CPT Codes


QEEG Oct 14

Functional cortical an subcortical mapping by stimulation

and/or recording of electrodes on brain surface, or of depth
electrodes, to provoke seizures or identify vital brain
structures; initial hour of attendance by a physician or other
qualified health care professional
Functional cortical an subcortical mapping by stimulation
and/or recording of electrodes on brain surface, or of depth
electrodes, to provoke seizures or identify vital brain
structures; each additional hour of attendance by a physician
or other qualified health care professional


Topographic brain mapping

Scientific Rationale Update October 2014

Rosenfeld et al (2014) evaluated all patients undergoing all-night polysomnography
for a sleep disorder over a two-year period for fibromyalgia. The polysomnograms
were interpreted for routine sleep measures and qEEG was performed to measure
the delta and alpha frequency power during non-REM sleep. Measures and qEEG
were analyzed according to fibromyalgia diagnosis. Of the 385 patients in the study
population, 133 had fibromyalgia according to American College of Rheumatology
criteria. The population's average Epworth Sleepiness Score was 10.5, the average
sleep efficiency was 78%, and the Periodic Limb Movement disorder prevalence was
15%. None of these sleep measures differed significantly between the fibromyalgia
and non-fibromyalgia groups. Obstructive sleep apnea was present in 45% of the
fibromyalgia group. Significant differences were present in the qEEG ratio of delta to
alpha frequency power, which was 95% specific for fibromyalgia when 1. A qEEG
ratio 10.5 was 85% sensitive for fibromyalgia and a qEEG ratio >10.5 had a 89%
negative predictive value for fibromyalgia. Among patients with fibromyalgia who
were not taking a benzodiazepine or benzodiazepine agonist, a qEEG ratio 10.5 was
84% specific and had a 78% positive predictive value. The investigators concluded
sleep disorders identified by routine polysomnography, including obstructive sleep
apnea, are common in fibromyalgia, but periodic leg movement disorder and poor
sleep efficiency are not. A qEEG low delta/alpha ratio during non-REM sleep can
differentiate patients with fibromyalgia from others who are referred for
polysomnography. Consideration of benzodiazepine and benzodiazepine agonist use
is important when interpreting the delta/alpha ratio.
Garn et al (2014) investigated which single quantitative EEG (qEEG) marker or
which combination of markers correlates best with Alzheimer's disease (AD) severity
as measured by the Mini-Mental State Examination (MMSE). The authors compared
qEEG markers for slowing (relative band powers), synchrony (coherence, canonical
correlation, Granger causality) and complexity (auto-mutual information,
Shannon/Tsallis entropy) in 118 AD patients from the multi-centric study PRODEM
Austria. Signal spectra were determined using an indirect spectral estimator.
Analyses were adjusted for age, sex, duration of dementia, and level of education.
For the whole group (39 possible, 79 probable AD cases) MMSE scores explained
33% of the variations in relative theta power during face encoding, and 31% of automutual information in resting state with eyes closed. MMSE scores explained also
25% of the overall QEEG factor. This factor was thus subordinate to individual
markers. In probable AD, QEEG coefficients of determination were always higher
than in the whole group, where MMSE scores explained 51% of the variations in
relative theta power. The authors concluded selected qEG markers show strong
associations with AD severity. Both cognitive and resting state should be used for
qEEG assessments.
Kim et al (2014) investigated the clinical utility of qEEG and the Integrated Visual
and Auditory Continuous Performance Test (IVA+CPT) as auxiliary tools for assessing
Attention Deficit Hyperactivity Disorder (ADHD). All of 157 subjects were assessed
using the Korean version of the Diagnostic Interview Schedule for Children Version
IV (DISC-IV). The authors measured EGG absolute power in 21 channels and
conducted IVA+CPT. They analyzed qEEG according to the Hz range: delta (1-4Hz),
theta (4-8Hz), slow alpha (8-10Hz), fast alpha (10-13.5Hz), and beta (13.5-30Hz).
To remove artifacts, independent component analysis was conducted (ICA), and the
tester confirmed the results again. All of the IVA+CPT quotients showed significant
differences between the ADHD and control groups. The ADHD group showed
significantly increased delta and theta activity compared with the control group. The
QEEG Oct 14

z-scores of theta were negatively correlated with the scores of IVA+CPT in ADHD
combined type, and those of beta were positively correlated. The authors concluded
IVA+CPT and QEEG significantly discriminated between ADHD and control groups.
The commission error of IVA+CPT showed an accuracy of 82.1%, and the omission
error of IVA+CPT showed an accuracy of 78.6%.
Garn et al (2014) reported qEEG recorded during cognitive tasks has been shown to
differentiate between patients with AD and healthy individuals. However, the
association between various qEEG markers recorded during mnestic paradigms and
clinical measures of AD has not been studied in detail. The authors sought to
evaluate if 'cognitive' qEEG is a useful diagnostic option, particularly if memory
paradigms are used as cognitive stimulators. This study is part of the Prospective
Registry on Dementia in Austria (PRODEM), a multicenter dementia research project.
A cohort of 79 probable AD patients was included in a cross-sectional analysis. qEEG
recordings performed in resting states were compared with recordings during
cognitively active states. Cognition was evoked with a face-name paradigm and a
paired-associate word list task, respectively. Relative band powers, coherence and
auto-mutual information were computed as functions of MMSE scores for the
memory paradigms and during rest. Analyses were adjusted for the co-variables age,
sex, duration of dementia and educational level. MMSE scores explained 36-51% of
the variances of qEEG-markers. Face-name encoding with eyes open was superior to
resting state with eyes closed in relative theta and beta1 power as well as
coherence, whereas relative alpha power and auto-mutual information yielded more
significant results during resting state with eyes closed. The face-name task yielded
stronger correlations with MMSE scores than the verbal memory task. The authors
concluded qEEG alterations recorded during mnestic activity, particularly face-name
encoding showed the highest association with the MMSE and may serve as a clinically
valuable marker for disease severity.

Scientific Rationale Initial

Electroencephalography (EEG) is a test that measures and records the electrical
activity of the brain using a number of electrodes that are placed around the scalp.
Quantitative EEG (QEEG), also called brain mapping, is the mathematical processing
of 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.
QEEG analysis techniques can provide additional measurements or displays of EEG in
ways not available with analog paper EEG recordings. QEEG techniques include
topographic displays of voltage or frequency, statistical comparisons to normative
values, and discriminant analysis.
The American Academy of Neurologys assessment of digital EEG, quantitative EEG
and EEG brain mapping (1997), reports that despite potential advantages, QEEGs
clinical usefulness is quite limited although it has been investigated for numerous
indications. Techniques used in QEEG vary substantially between laboratories, and
any clinical usefulness found with one specific technique may not apply when using a
different technique.
At this time, QEEG has been accepted for clinical application in some areas, such as
epilepsy, certain individuals with cerebro-vascular disorders, dementia or
encephalopathy, when neuroimaging and routine EEG studies are inconclusive.
QEEG has yet to be accepted in other clinical areas, such as diagnosing mild
traumatic brain injury or psychiatric disorders. The use of QEEG techniques in
investigations in clinical and research settings are on going.

QEEG Oct 14

Chen et al (2013) reported slowing of average EEG frequency in Alzheimer's disease

(AD) is well established, but whether EEG changes are able to reflect the severity of
AD is uncertain. Investigators attempted to establish quantitative EEG parameters
that are suitable for evaluating AD in clinical practice. Ninety-five patients with
newly diagnosed AD at different stages from four neurologic institutes were enrolled
for the study. Standard scalp resting EEG data were collected for quantitative
analysis. Global band power ratio and interhemispheric alpha band coherence were
calculated. Patients with advanced AD had a greater slow-to-fast wave power ratio.
Among several power ratio parameters, global theta and delta to alpha and beta
band power ratio showed the best correlation with stages of AD (p < 0.05 between
any two patient groups). Patients with advanced AD had decreased coherence in
multiple brain regions. The phenomenon was most prominent in the centroparietal
region (p < 0.05 between any two patient groups). Investigators concluded
increased global slow-to-fast power ratio and decreased centroparietal
interhemispheric alpha band coherence are strongly correlated with disease progress
in AD patients. These two quantitative EEG parameters may help evaluate AD
patients in daily clinical practice. Global power ratio changes may suggest a shift of
dominant frequency, and decreased interhemispheric alpha band coherence may
suggest functional disconnection and corpus callosum abnormalities in AD patients.
Bjrk et al (2011) reported QEEG frequency spectra and steady-state visual-evoked
potentials (SSVEP) are indicators of corticothalamic excitability (e.g., arousal).
Increased interictal excitability is suggested to be an important element in the
migraine pathophysiology. The authors summarize their results from four studies of
QEEG and SSVEP recordings in migrainers interictally and in the days before an
attack with the intention to shed light on attack-initiating mechanisms. Thirty-two
healthy controls, 33 migrainers without and eight with aura each had three EEGs
with photic stimulation on different days. Using the patient headache diaries, they
classified the recordings as interictal, preictal, ictal, or post-ictal retrospectively.
Interictal recordings were compared pairwise with attack-related EEGs from the
same patient as well as with control EEGs. They also correlated clinical variables with
the QEEG and SSVEP data. Between attacks, they found increased relative theta
activity and attenuated medium-frequency photic responses in migrainers without
aura compared with those in controls. Within 36 h before the attack, slow and
asymmetric EEG activity developed. Increased trigger sensitivity and photophobia
correlated with higher theta power and depressed photic responses. Attack duration,
migraine history duration, and pain intensity were associated with EEG slowing. The
authors concluded a general tendency toward EEG slowing and depression of photic
responses characterized the migraine group. This pattern was also related to
increased severity of symptoms. A change in cortical activity occurred within 36 h
before attacks. The results indicate that thalamocortical hypoexcitability is associated
with attack initiation and sensory hypersensitivity in migraine.
Ommundsen et al (2011) evaluated the use of QEEG statistical pattern recognition in
diagnosing AD. QEEG was performed on 104 patients referred to a memory clinic.
The QEEG results were compared to the clinical diagnosis made without access to the
EEG results. Of 30 patients with a clinical diagnosis of AD, 22 were test positive. Of
the 74 patients without AD, 34 were test negative. The QEEG result was found to
correlate with atrophy of the medial temporal lobe demonstrated on cerebral MRI (p
= 0.002) and with scores on neuropsychological tests. Investigators concluded
QEEG was poor at diagnosing AD, as it produced many false-positive results
McCrea et al (2010) investigated the clinical utility and sensitivity of a portable,
automatic, frontal QEEG acquisition device currently in development in detecting
abnormal brain electrical activity after sport-related concussion. A prospective, nonrandomized study of 396 high school and college football players, including cohorts
QEEG Oct 14

of 28 athletes with concussion and 28 matched controls underwent preseason

baseline testing on measures of postconcussive symptoms, postural stability, and
cognitive functioning, as well as QEEG. Clinical testing and QEEG were repeated on
day of injury and days 8 and 45 postinjury for the concussion and control groups.
The injured group reported more significant postconcussive symptoms during the
first 3 days postinjury, which resolved by days 5 and 8. Injured subjects also
performed poorer than controls on neurocognitive testing on the day of injury, but no
differences were evident on day 8 or day 45. QEEG studies revealed significant
abnormalities in electrical brain activity in the injured group on day of injury and day
8 postinjury, but not on day 45. Investigators concluded the reesults from the
current study on clinical recovery after sport-related concussion are consistent with
early reports indicating a typical course of full recovery in symptoms and cognitive
dysfunction within the first week of injury. QEEG results, however, suggest that the
duration of physiological recovery after concussion may extend longer than observed
clinical recovery. Further study is required to replicate and extend these findings in a
larger clinical sample, and further demonstrate the utility of QEEG as a marker of
recovery after sport-related concussion.
Gawel et al (2009) investigated whether QEEG may be useful in differential diagnosis
of AD and subcortical vascular dementia (SVD) and to determine the correlation
between dementia and abnormalities in EEG. The group under study was consisted of
62 patients with AD (mean age: 73.6 yrs; M 51%), 31 with SVD (mean age: 75.2
yrs, M 43%) and a control group of 14 healthy subjects (mean age: 69.5 yrs, M
43%). The patients were divided into subgroups of those with mild, moderate and
marked dementia. EEG findings were classified using eight-degree scale according to
the presence of slow waves, and then quantitative analysis was carried out by
calculating the alpha/slow wave power ratios and the mean frequencies in all and
some selected derivations. A significant difference between visual EEGs and QEEGs in
AD and SVD was found. Only QEEG parameters differed in AD and SVD subgroups
with the same degree of cognitive impairment: the mean wave frequencies of waves
in temporal derivations in subgroups with mild and moderate dementia and
alpha/delta waves power ratio in subgroups with moderate dementia. Investigators
concluded visual EEGs and QEEGs could be used in addition to the differential
diagnosis between AD and SVD, but only selected parameters of QEEG could be
useful in differentiating between AD and SVD subgroups with the same degree of

Review History
October 2013
October 2014

Medical Advisory Council, initial approval

Update no revisions

This policy is based on the following evidence-based guidelines:


Nuwer M. Assessment of digital EEG, quantitative EEG, and EEG brain mapping:
Report of the American Academy of Neurology and the American Clinical
Neurophysiology Society. Neurology. 1997;49(1):277-292. Available at:

References Update October 2014


Bonanni L, Perfetti B, Bifolchetti S, et al. Quantitative electroencephalogram

utility in predicting conversion of mild cognitive impairment to dementia with
Lewy bodies. Neurobiol Aging. 2014 Jul 15.
Braga AS, Assis BD, Ribeiro JT, et al. Quantitative EEG evaluation in patients
with acute encephalopathy. Arq Neuropsiquiatr. 2013 Dec;71(12):937-42.

QEEG Oct 14


Garn H, Waser M, Deistler M, et al. Quantitative EEG markers relate to

Alzheimer's disease severity in the Prospective Dementia Registry Austria
(PRODEM). Clin Neurophysiol. 2014 Jul 12. pii: S1388-2457(14)00368-X.
4. Garn H, Waser M, Deistler M, et al. Quantitative EEG in Alzheimer's disease:
cognitive state, resting state and association with disease severity. Int J
Psychophysiol. 2014 Sep;93(3):390-7.
5. Herron K, Dijk DJ, Dean P, et al. Quantitative electroencephalography and
behavioural correlates of daytime sleepiness in chronic stroke. Biomed Res Int.
6. Kim J, Lee Y, Han D, et al. The utility of quantitative electroencephalography
and Integrated Visual and Auditory Continuous Performance Test as auxiliary
tools for the Attention Deficit Hyperactivity Disorder diagnosis. Clin
Neurophysiol. 2014 Jul 5.
7. Lin LC, Ouyang CS, Chiang CT, et al. Early evaluation of the therapeutic
effectiveness in children with epilepsy by quantitative EEG: A model of Mozart
K.448 listening-a preliminary study. Epilepsy Res. 2014 Oct;108(8):1417-26.
8. Ogrim G, Kropotov J, Brunner JF, et al. Predicting the clinical outcome of
stimulant medication in pediatric attention-deficit/hyperactivity disorder: data
from quantitative electroencephalography, event-related potentials, and a
go/no-go test. Neuropsychiatr Dis Treat. 2014 Feb 3;10:231-42.
9. Rosenfeld V, Rutledge D, Stern JM. .Polysomnography with Quantitative EEG in
Patients with and without Fibromyalgia. J Clin Neurophysiol. 2014 Sep 16.
10. Sarkis RA, Lee JW. Quantitative EEG in hospital encephalopathy: review and
microstate analysis.. J Clin Neurophysiol. 2013 Oct;30(5):526-30.
11. Song Y, Zang DW, Jin YY, et al. Background Rhythm Frequency and Theta
Power of Quantitative EEG Analysis: Predictive Biomarkers for Cognitive
Impairment Post-Cerebral Infarcts. Clin EEG Neurosci. 2014 Apr 2. [
12. van Tricht MJ, Ruhrmann S, Arns M, et al. Can quantitative EEG measures
predict clinical outcome in subjects at Clinical High Risk for psychosis? A
prospective multicenter study. Schizophr Res. 2014 Mar;153(1-3):42-7.

References Initial


Bares M, Novak T, Brunovsky M, et al. The change of QEEG prefrontal cordance

as a response predictor to antidepressive intervention in bipolar depression. A
pilot study. J Psychiatr Res. 2012 Feb;46(2):219-25.
Begi D, Popovi-Knapi V, Grubiin J, et al. Quantitative
electroencephalography in schizophrenia and depression. Psychiatr Danub. 2011
Billeci L, Sicca F, Maharatna K, et al. On the application of quantitative EEG for
characterizing autistic brain: a systematic review. Front Hum Neurosci.
Bjrk M, Stovner LJ, Hagen K, Sand T. .What initiates a migraine attack?
Conclusions from four longitudinal studies of quantitative EEG and steady-state
visual-evoked potentials in migraineurs. Acta Neurol Scand Suppl.
Bjrk MH, Stovner LJ, Engstrm M, et al. Interictal quantitative EEG in
migraine: a blinded controlled study. J Headache Pain. 2009 Oct;10(5):331-9.
Bjrk M, Sand T. .Quantitative EEG power and asymmetry increase 36 h before
a migraine attack. Cephalalgia. 2008 Sep;28(9):960-8.
Chen CC, Hsu CY, Chiu HW, Hu CJ, Lee TC. Frequency power and coherence of
electroencephalography are correlated with the severity of Alzheimer's disease:
A multicenter analysis in Taiwan. J Formos Med Assoc. 2013 Aug 19.
Fonseca LC, Tedrus GM, Prandi LR, Andrade AC. Quantitative
electroencephalography power and coherence measurements in the diagnosis of
mild and moderate Alzheimer's disease. Arq Neuropsiquiatr. 2011;69(2B):297303.

QEEG Oct 14




Gawel M, Zalewska E, Szmidt-Sakowska E, Kowalski J. The value of

quantitative EEG in differential diagnosis of Alzheimer's disease and subcortical
vascular dementia. J Neurol Sci. 2009 Aug 15;283(1-2):127-33.
Haneef Z, Levin HS, Frost JD Jr, Mizrahi EM. .Electroencephalography and
quantitative electroencephalography in mild traumatic brain injury. J
Neurotrauma. 2013 Apr 15;30(8):653-6
Hargrove JB, Bennett RM, Simons DG, et al. Quantitative
electroencephalographic abnormalities in fibromyalgia patients. Clin EEG
Neurosci. 2010 Jul;41(3):132-9.
Hasey GM, Kiang M. A review of recent literature employing
electroencephalographic techniques to study the pathophysiology,
phenomenology, and treatment response of schizophrenia. Curr Psychiatry Rep.
2013 Sep;15(9):388.
Kim JS, Lee SH, Park G, et al. Clinical implications of quantitative
electroencephalography and current source density in patients with Alzheimer's
disease. Brain Topogr. 2012 Oct;25(4):461-74.
Klassen BT, Hentz JG, Shill HA, et al. Quantitative EEG as a predictive
biomarker for Parkinson disease dementia. Neurology. 2011 Jul 12;77(2):11824.
Leuchter AF, Cook IA, Hunter AM, et al. Resting-state quantitative
electroencephalography reveals increased neurophysiologic connectivity in
depression. PLoS One. 2012;7(2):e32508.
McCrea M, Prichep L, Powell MR, et al. Acute effects and recovery after sportrelated concussion: a neurocognitive and quantitative brain electrical activity
study. J Head Trauma Rehabil. 2010 Jul-Aug;25(4):283-92
Nishida K, Yoshimura M, Isotani T, et al. Differences in quantitative EEG
between frontotemporal dementia and Alzheimer's disease as revealed by
LORETA. Clin Neurophysiol. 2011 Sep;122(9):1718-25.
Ogrim G, Hestad KA, Brunner JF, Kropotov J. Predicting acute side effects of
stimulant medication in pediatric attention deficit/hyperactivity disorder: data
from quantitative electroencephalography, event-related potentials, and a
continuous-performance test. Neuropsychiatr Dis Treat. 2013;9:1301-9.
Ommundsen N, Engedal K, ksengrd AR. Validity of the quantitative EEG
statistical pattern recognition method in diagnosing Alzheimer's disease.
Dement Geriatr Cogn Disord. 2011;31(3):195-201.
Todder D, Levine J, Abujumah A, et al. The quantitative electroencephalogram
and the low-resolution electrical tomographic analysis in posttraumatic stress
disorder. Clin EEG Neurosci. 2012 Jan;43(1):48-53.
Sackellares JC, Shiau DS, Halford JJ, et al. Quantitative EEG analysis for
automated detection of nonconvulsive seizures in intensive care units. Epilepsy
Behav. 2011 Dec;22 Suppl 1:S69-73.
Sheikhani A, Behnam H, Mohammadi MR, et al. Detection of abnormalities for
diagnosing of children with autism disorders using of quantitative
electroencephalography analysis. J Med Syst. 2012 Apr;36(2):957-63
Viirre ES. Quantitative electroencephalography for tinnitus--a means for data
collection, analysis, and translation. Int Tinnitus J. 2009;15(2):149-53.

Important Notice
General Purpose.
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering
plan benefits and determining whether a particular procedure, drug, service or supply is medically
necessary. The Policies are based upon a review of the available clinical information including clinical
outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device,
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and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract,
including medical necessity requirements. Health Net may use the Policies to determine whether under the

QEEG Oct 14

facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically
necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not
constitute coverage. The member's contract defines which procedure, drug, service or supply is covered,
excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current
criteria that have been approved by Health Nets National Medical Advisory Council (MAC). The clinical
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Reconstructive Surgery
CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery.
Reconstructive surgery means surgery performed to correct or repair abnormal structures of the body
caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do
either of the following:
(1) To improve function or
(2) To create a normal appearance, to the extent possible.
Reconstructive surgery does not mean cosmetic surgery," which is surgery performed to alter or reshape
normal structures of the body in order to improve appearance.

QEEG Oct 14


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal
improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by
physicians specializing in reconstructive surgery.
Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices
or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy.
Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or
deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and
conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for
medically necessary reasons, as determined by a licensed physician and surgeon.
Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and
determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid
members shall not be construed to apply to any other Health Net plans and members. The Policies shall
not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.

QEEG Oct 14