G40.001 Insurance Policy Changes

ICD-10 G40.001 is officially defined as "Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus." code G40.001 is referenced in 26 tracked payer policy changes from Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code G40.001 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Excellus BlueCross BlueShield · Effective May 15, 2026High impact
Positron Emission Tomography (PET) – Head Imaging 6.01.47
Effective May 15, 2026, Excellus BCBS policy 6.01.47 sets the criteria for PET head imaging, which were removed from CMP 6.01.07. The 01/22/26 update added a medically necessary statement for amyloid brain PET (CPT 78814 or 78811) when a diagnosis of MCI or dementia due to Alzheimer disease is suspected, and a statement that perfusion PET brain (CPT 78609) is not medically necessary in the evaluation of dementia. FDG brain PET (CPT 78608) is medically necessary for mild cognitive impairment, dementia evaluation, Lewy body dementia versus Alzheimer disease, suspected encephalitis, and pre-surgical evaluation of refractory seizure when all listed criteria are met, and it is not medically necessary for Parkinson disease, normal pressure hydrocephalus, or chronic traumatic encephalopathy.
Excellus BlueCross BlueShield · Effective Aug 20, 2026Medium impact
Vagus Nerve Stimulation and Vagus Nerve Blocking Therapy 7.01.05
Implanted vagus nerve stimulation is medically appropriate as a treatment for medically refractory seizures, and it is investigational as a treatment for depression or any other non-epileptic condition. Vagus nerve stimulation implants that detect and stimulate based on increased heart rate, such as the AspireSR Model, are investigational for all indications, and vagus nerve blocking therapy is investigational as a treatment for morbid obesity. The August 20, 2026 update was an annual review with the policy intent unchanged.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2025Medium impact
Genetic Testing for Epilepsy
Already effective 2025-10-01: the code reference added ICD-10 diagnosis code QA0.0101 for SCN2A-related neurodevelopmental disorder. Genetic testing for genes associated with infantile- and early-childhood-onset epilepsy syndromes, in which epilepsy is the core clinical symptom, may be considered medically necessary when positive test results may lead to changes in medication management, changes in diagnostic testing so that alternative potentially invasive tests are avoided, or changes in reproductive decision making. Genetic testing for epilepsy is considered investigational for all other situations.
Aetna · Identified Oct 28, 2026Medium impact
Motor Cortex Stimulation (CPB 0755, reviewed 2026-10-21)
Aetna's Clinical Policy Bulletin 0755 says Aetna considers motor cortex stimulation experimental, investigational, or unproven for the listed indications because its effectiveness has not been established. The listed indications include amyotrophic lateral sclerosis, autism spectrum disorder, cerebral palsy, chronic refractory pain, depression, dysphagia, Parkinson's disease, post-stroke aphasia, post-stroke hemiparesis, seizures, traumatic brain injury and obsessive compulsive disorder, and the bulletin says that list is not all-inclusive. The bulletin also lists CPT, HCPCS and ICD-10 codes that are not covered for the indications listed in the policy.
Aetna · Identified Oct 27, 2026Medium impact
Selected Techniques for Delivery of Drugs to the Brain (CPB 0731, reviewed 2026-10-21)
Aetna Clinical Policy Bulletin 0731 (last review 10/21/2026) states that convection-enhanced delivery of drugs into brain parenchyma and low-intensity MR-guided focused ultrasound mediated disruption of the blood-brain barrier for drug delivery are experimental, investigational, or unproven because their safety and effectiveness have not been established. The policy lists CPT 0947T and several ICD-10 codes, including those for malignant neoplasm of brain, Alzheimer's disease, and epilepsy, as not covered for the indications listed in the bulletin.
Aetna · Identified Oct 23, 2026Medium impact
Actigraphy and Accelerometry (CPB 0710, reviewed 2026-10-15)
Aetna considers actigraphy testing (for example, Actiwatch) and accelerometry experimental, investigational, or unproven for listed uses, including diagnosing sleep disorders, diagnosing Alzheimer's disease, diagnosing hypertension, detecting seizures during sleep, and monitoring individuals with motor neuron diseases. CPT 95803 (actigraphy testing, minimum of 72 hours to 14 consecutive days of recording) and many listed ICD-10 codes, including those for depression, schizophrenia, Parkinson's disease and cerebral infarction, are not covered for the indications listed.
Aetna · Identified Oct 22, 2026Medium impact
Ziconotide (Prialt) (CPB 0712, reviewed 2026-10-14)
Aetna considers intrathecal ziconotide (Prialt) medically necessary for members with severe chronic pain that is intolerant of or refractory to other treatments, such as systemic analgesics, adjunctive therapies, or intrathecal morphine. Aetna considers it not medically necessary for members with a pre-existing history of psychosis, an infection at the micro-infusion injection site, uncontrolled bleeding diathesis, or spinal canal obstruction. Aetna considers intrathecal ziconotide experimental, investigational, or unproven for autism, epilepsy, Irukandji syndrome, migraines, primary lateral sclerosis, stroke and other indications, and considers the intrathecal combination of ziconotide, morphine and levobupivacaine experimental for cancer-related refractory pain.
Aetna · Identified Oct 5, 2026Medium impact
Lead Testing (CPB 0553, reviewed 2026-08-28)
Aetna considers blood lead testing medically necessary for diagnosis of persons with signs and symptoms of lead poisoning and for pregnant or lactating women who have any listed lead exposure risk factor. Lead screening is covered for persons with occupational lead exposure and, as a preventive service, for children in listed high-risk groups. Measurement of lead in bone, hair, teeth, or urine is considered experimental, investigational, or unproven.
Aetna · Identified Oct 4, 2026Medium impact
Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation (CPB 0599, reviewed 2026-09-18)
Autologous skeletal myoblast transplantation, intra-coronary and intra-myocardial autologous bone marrow cell transplantation, and intra-arterial or intra-muscular autologous mononuclear bone marrow cell transplantation are considered experimental, investigational, or unproven because effectiveness has not been established. Autologous or allogeneic bone marrow-derived mesenchymal stem cell transplantation is likewise considered experimental, investigational, or unproven for conditions including acute myocardial infarction, diabetes, multiple sclerosis, knee osteoarthritis, spinal cord injury, rheumatoid arthritis, Crohn's disease, and peripheral nerve repair. CPT codes 0263T, 0264T, 0265T, 38240, and 38241 and HCPCS code C9782 are listed as not covered for the listed indications, and the ICD-10 codes for those indications are listed as not covered for these services.
Aetna · Identified Aug 18, 2026Medium impact
Vagus Nerve Stimulation (CPB 0191, reviewed 2026-03-31)
Aetna's Vagus Nerve Stimulation policy (CPB 0191, reviewed March 31, 2026) considers vagus nerve electrical stimulators medically necessary durable medical equipment for focal seizures or Lennox-Gastaut syndrome in members who remain refractory to optimal anti-epileptic medications and/or surgical intervention, or who have debilitating side effects from anti-epileptic medications, and who have no history of a bilateral or left cervical vagotomy. Replacement or revision of a system is considered medically necessary when the original system met criteria, is no longer under warranty, and cannot be repaired. Integrated VNS for multiple sclerosis, psoriatic arthritis and rheumatoid arthritis, transcutaneous VNS for seizures and post-laminectomy syndrome, VNS for prevention of chronic migraine, and VNS for all other listed indications (such as depression, obesity and tinnitus) are considered experimental, investigational or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Obsolete and Unreliable Tests and Procedures (CPB 0438, reviewed 2026-07-16)
Aetna considers a list of tests experimental, investigational, or unproven because CMS has determined they are obsolete or unreliable, they have been replaced by more advanced procedures, or professional specialty societies do not recommend them, and the list includes the lupus erythematosus cell test, cardiointegram, and several serum and skin tests. Aetna also considers a set of obsolete procedures experimental, investigational, or unproven, including colectomy to treat epilepsy, mammary artery ligation for coronary artery disease, optic nerve decompression for non-arteritic anterior ischemic optic neuropathy, radiation therapy for acne, Ali Krogius procedure for patellofemoral instability, and visceral osteopathy. Each listed test or procedure has CPT, HCPCS, or ICD-10 codes that are not covered for the indications the policy names.
Aetna · Identified Aug 18, 2026Medium impact
Hospitalization for the Initiation of Ketogenic Diet (CPB 0226, reviewed 2026-04-23)
Aetna considers hospitalization for initiation of a ketogenic diet medically necessary for intractable seizures, including Doose syndrome and Lennox-Gastaut syndrome, when all listed selection criteria are met, and for persons with glucose transporter protein type 1 deficiency or pyruvate dehydrogenase complex deficiency. Aetna considers hospitalization for initiation of a ketogenic diet of unproven value for all other indications, including adult super-refractory status epilepticus, Alzheimer's disease, autism spectrum disorder, cancer, migraine prevention, multiple sclerosis, Parkinson's disease, schizophrenia and type 2 diabetes. Hospitalization for initiation of the Atkins diet for intractable seizures, mitochondrial diseases, or other indications is considered experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Fetal Echocardiography and Magnetocardiography (CPB 0106, reviewed 2026-03-26)
Aetna considers fetal echocardiograms, Doppler and color flow mapping after 12 weeks gestation medically necessary for listed indications. These include a mother with type 1 diabetes or pregestational type 2 diabetes on insulin during the first trimester, a mother with systemic lupus erythematosus, a fetal nuchal translucency of 3.5 mm or greater in the first trimester, pregnancies conceived by IVF or ICSI, monochorionic twins, suspected twin-twin transfusion syndrome, suspected or documented fetal arrhythmia, suspected or known fetal chromosomal abnormalities, single umbilical artery, persistent right umbilical vein, non-immune fetal hydrops or unexplained severe polyhydramnios, and seizure disorders in members even if they are not taking anti-seizure medication. Fetal exposure to anti-seizure medications, excessive alcohol, lithium, paroxetine or retinoids is also a listed indication. Repeat studies are covered for listed findings and for fetal surveillance of anti-Ro (SSA) or anti-La (SSB) exposure, which may be repeated every 1 to 2 weeks starting at 16 weeks gestation through 28 weeks, then every other week until 32 weeks. Fetal echocardiograms for advanced maternal age screening, gestational diabetes even if requiring insulin after the first trimester, modafinil exposure, selective serotonin reuptake inhibitors except paroxetine, tacrolimus, a tortuous ductus arteriosus, and suspected cystic fibrosis are experimental, investigational or unproven. Fetal magnetocardiography and deep learning-based models for diagnosing fetal arrhythmia are also experimental, investigational or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Motor Cortex Stimulation (CPB 0755, reviewed 2026-02-24)
Aetna's Clinical Policy Bulletin 0755 on motor cortex stimulation, with a policy history last review of 10/21/2026, considers motor cortex stimulation experimental, investigational or unproven for many indications because its effectiveness has not been established. The list includes amyotrophic lateral sclerosis, autism spectrum disorder, cerebral palsy, chronic refractory pain (such as central pain syndromes, complex regional pain syndrome, phantom limb pain, thalamic pain and trigeminal neuropathic pain), depression, dysphagia, dystonia secondary to a focal basal ganglia lesion, movement disorders, obsessive compulsive disorder, Parkinson's disease, post-stroke aphasia, post-stroke hemiparesis, seizures, traumatic brain injury, and use of motor cortex stimulation during deep brain stimulator implantation. The policy lists CPT codes 61850, 61860, 61885, 61886, 64568, 95961, 95962 and 95970 as not covered for the indications it lists.
Aetna · Identified Aug 17, 2026Medium impact
Stereotactic Radiosurgery (CPB 0083, reviewed 2026-03-11)
Aetna considers stereotactic radiosurgery (SRS) medically necessary in certain circumstances, and refers to the eviCore Healthcare Radiation Therapy Clinical Guidelines for medical necessity criteria. Cranial SRS is medically necessary for benign brain and spinal tumors, cranial arteriovenous malformations, cavernous malformations and hemangiomas, trigeminal neuralgia that has not responded to more conservative treatments, severe essential tremor not adequately responsive to standard medical therapy, disabling tremor in Parkinson's disease for patients who meet thalamotomy criteria but are not surgical candidates, and primary brain tumors and primary or secondary tumors involving the spine. For brain metastases, SRS is considered appropriate with a Karnofsky Performance Status of 40 or greater (or expected to return to 70 or greater), or an ECOG status of 3 or less (or expected to return to 2 or less), fewer than 10 metastatic lesions, and control of or expected control of extracranial disease. Stereotactic body radiation therapy is medically necessary for liver or hepatobiliary cancer stage I to II, organ-confined prostate cancer, inoperable stage I or IIA lung cancer, unresectable stage I to III pancreatic cancer, recurrent disease requiring re-irradiation, and oligometastatic breast, non-small cell lung, colorectal, renal cell, prostate, sarcoma, melanoma and head and neck cancers with 1 to 5 total metastases, and Aetna considers SRS experimental, investigational, or unproven for cluster headaches, epilepsy (except when associated with treatment of arteriovenous malformations or brain tumors), and mammographic microcalcification.
Aetna · Identified Aug 16, 2026Medium impact
Selected Techniques for Delivery of Drugs to the Brain (CPB 0731, reviewed 2025-11-26)
Aetna considers convection-enhanced delivery of drugs into the brain parenchyma experimental, investigational, or unproven. Aetna also considers low-intensity MR-guided focused ultrasound (MRgFUS) mediated disruption of the blood-brain barrier for enhanced drug delivery into the brain experimental, because the safety and effectiveness of these approaches have not been established. CPT code 0947T for MRgFUS stereotactic blood-brain barrier disruption is not covered for the indications listed, and ICD-10 codes for brain malignancies, Alzheimer's disease, epilepsy and seizures are listed as not covered.
Aetna · Identified Aug 15, 2026Medium impact
Quantitative EEG (Brain Mapping) (CPB 0221, reviewed 2026-04-14)
Aetna considers quantitative EEG (brain mapping, also called BEAM) medically necessary only as an adjunct to traditional EEG for specified uses, including ambulatory EEG recording to facilitate later expert visual interpretation, continuous EEG monitoring by frequency-trending in the operating room or ICU, and topographic voltage and dipole analysis in pre-surgical evaluations for intractable epilepsy. Aetna considers quantitative EEG experimental, investigational or unproven for all other indications, including attention disorders, autism spectrum disorders, depression, schizophrenia, bipolar disorder, insomnia, fibromyalgia, post-traumatic stress disorder and post-concussion syndrome. The BrainScope One System (Ahead 300) is considered experimental, investigational or unproven for evaluation of concussion or traumatic brain injury.
Aetna · Identified Aug 15, 2026Medium impact
Fecal Bacteriotherapy (CPB 0844, reviewed 2026-03-25)
Aetna's commercial clinical policy bulletin 0844 covers fecal bacteriotherapy. It considers fecal microbiota transplant medically necessary for Clostridium difficile infection (CDI) confirmed by a positive C. difficile toxin stool test that has recurred after at least one course of adequate antibiotic therapy. It considers a single rectal dose of Rebyota (fecal microbiota, live-jslm) medically necessary for preventing CDI when the policy's criteria are met, and it considers other listed indications, including alcoholic hepatitis, Crohn's disease, ulcerative colitis and irritable bowel syndrome, experimental, investigational, or unproven.
Aetna · Identified Aug 15, 2026Medium impact
Carbogen Inhalation Therapy (CPB 0428, reviewed 2026-07-09)
Carbogen inhalation therapy (5% carbon dioxide and 95% oxygen) is considered experimental, investigational, or unproven for bladder cancer, central retinal artery occlusion, cervical cancer, fracture healing, head and neck cancers, optic nerve damage or degeneration, prostate cancer, retinal artery occlusion, seizures, stroke, and sudden hearing loss. The policy lists no specific CPT or HCPCS code for carbogen inhalation therapy, and the ICD-10 diagnosis codes for these indications are listed as not covered for carbogen inhalation therapy. The policy was last reviewed 07/09/2026.
Aetna · Identified Aug 14, 2026Medium impact
Deep Brain Stimulation (CPB 0208, reviewed 2026-03-27)
Aetna considers unilateral or bilateral deep brain stimulation medically necessary durable medical equipment for intractable tremor from Parkinson's disease or essential tremor, for severe refractory motor complications of Parkinson's disease, and for intractable primary dystonia in persons 7 years of age or older, each when the listed criteria are met. Aetna also considers bilateral stimulation of the anterior nucleus of the thalamus medically necessary for adults 18 years or older with partial onset seizures that have not responded to 3 or more antiepileptic medications. DBS for tremor from other causes and for listed indications such as Alzheimer's disease, depression, obsessive-compulsive disorder and chronic cluster headache is considered experimental, investigational, or unproven.
Aetna · Identified Aug 12, 2026Medium impact
Ambulatory Electroencephalography (CPB 0425, reviewed 2026-07-07)
Aetna considers ambulatory EEG, with or without home video monitoring, medically necessary to classify seizure type in members with epilepsy when routine EEG is equivocal, to diagnose a seizure disorder when history, examination and routine EEG do not resolve the diagnostic uncertainty, and to localize the epileptogenic region during pre-surgical evaluation. These indications apply where the member has had a neurologic examination and standard EEG studies within the past 12 months. Combined ambulatory EEG and home-video recording is considered an equally acceptable alternative to ambulatory EEG alone, while ambulatory EEG for all other indications and implantable sub-scalp continuous EEG systems such as Epios and Minder for managing epilepsy are considered experimental, investigational or unproven.
Aetna · Identified Aug 12, 2026Medium impact
Actigraphy and Accelerometry (CPB 0710, reviewed 2025-10-14)
Aetna considers actigraphy testing experimental, investigational, or unproven for indications including defining lithium response dimensions in bipolar disorders, detection or screening of apnea, diagnosis of Alzheimer's disease, diagnosis of hypertension, evaluation of depression, and evaluation of schizophrenia. Aetna considers accelerometry experimental, investigational, or unproven for indications including evaluating functional ability in the elderly, differential diagnosis of tremor syndromes, gait analysis in persons with hip osteoarthritis, and monitoring of physical activity during rehabilitation of persons with stroke. CPT code 95803 (actigraphy testing, recording, analysis, interpretation and report, minimum of 72 hours to 14 consecutive days of recording) and CPT codes 0533T through 0536T (continuous recording of movement disorder symptoms) are not covered for the indications listed in the policy.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
Responsive neurostimulation may be considered medically necessary for individuals with focal epilepsy who are 18 years or older, have focal seizures with 1 or 2 well-localized seizure foci, average 3 or more disabling seizures per month over the prior 3 months, have failed 2 or more appropriate antiepileptic medications at therapeutic doses, are not candidates for focal resective epilepsy surgery, and have no contraindications to device placement. Responsive neurostimulation is considered investigational for all other indications. The policy was last reviewed on 06/06/2025 with no changes.
Health Net · Identified Jun 20, 2026Medium impact
20-947 Medical Policies - 3rd Quarter 2020
Medical policies approved in the third quarter of 2020 may apply to CalViva Health Medi-Cal members in Fresno, Kings and Madera counties where no California DHCS policy is available. New policies cover respiratory viral panel testing, thymus transplantation and related criteria, while updated policies change criteria for services such as trigger point injections (now a maximum of four per year, down from six), sacroiliac joint fusion, sacral nerve stimulation and mechanical stretching devices. Some codes were added, moved or removed, including L8613 (removed) and L8692 (added) for bone-anchored hearing aids.
Health Net · Identified Jun 20, 2026Medium impact
20-944 Medical Policies - 3rd Quarter 2020
Medical policies approved in the third quarter of 2020 by Centene's Corporate Clinical Policy Committee and/or Health Net's Medical Advisory Council include new policies for respiratory viral panel testing and thymus transplantation, and updated criteria for services such as trigger point injections (now a maximum of four per year, down from six), sacroiliac joint fusion, sacral nerve stimulation and mechanical stretching devices. Some codes were added, moved or removed, including L8613 (removed) and L8692 (added) for bone-anchored hearing aids.
Health Net · Identified Jun 20, 2026Medium impact
20-946 Medical Policies - 3rd Quarter 2020
Medical policies approved in the third quarter of 2020 by Centene's Corporate Clinical Policy Committee and/or Health Net's Medical Advisory Council include new policies for respiratory viral panel testing and thymus transplantation, and updated criteria for services such as trigger point injections (now a maximum of four per year, down from six), sacroiliac joint fusion, sacral nerve stimulation and mechanical stretching devices. Some codes were added, moved or removed, including L8613 (removed) and L8692 (added) for bone-anchored hearing aids. For Cal MediConnect members, Medicare and Medicaid national and local policies must be applied first for primary coverage guidance.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code G40.001?

There are 26 tracked policy changes affecting code G40.001, including updates from Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code G40.001?

Payers that have issued tracked updates for code G40.001 include: Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, Aetna, Health Net.

How do I get notified when code G40.001 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code G40.001. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code G40.001?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

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Positron Emission Tomography (PET) – Head Imaging 6.01.47

Vagus Nerve Stimulation and Vagus Nerve Blocking Therapy 7.01.05

Genetic Testing for Epilepsy

Motor Cortex Stimulation (CPB 0755, reviewed 2026-10-21)

Selected Techniques for Delivery of Drugs to the Brain (CPB 0731, reviewed 2026-10-21)

Actigraphy and Accelerometry (CPB 0710, reviewed 2026-10-15)

Ziconotide (Prialt) (CPB 0712, reviewed 2026-10-14)

Lead Testing (CPB 0553, reviewed 2026-08-28)

Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation (CPB 0599, reviewed 2026-09-18)

Vagus Nerve Stimulation (CPB 0191, reviewed 2026-03-31)

Obsolete and Unreliable Tests and Procedures (CPB 0438, reviewed 2026-07-16)

Hospitalization for the Initiation of Ketogenic Diet (CPB 0226, reviewed 2026-04-23)

Fetal Echocardiography and Magnetocardiography (CPB 0106, reviewed 2026-03-26)

Motor Cortex Stimulation (CPB 0755, reviewed 2026-02-24)

Stereotactic Radiosurgery (CPB 0083, reviewed 2026-03-11)

Selected Techniques for Delivery of Drugs to the Brain (CPB 0731, reviewed 2025-11-26)

Quantitative EEG (Brain Mapping) (CPB 0221, reviewed 2026-04-14)

Fecal Bacteriotherapy (CPB 0844, reviewed 2026-03-25)

Carbogen Inhalation Therapy (CPB 0428, reviewed 2026-07-09)

Deep Brain Stimulation (CPB 0208, reviewed 2026-03-27)

Ambulatory Electroencephalography (CPB 0425, reviewed 2026-07-07)

Actigraphy and Accelerometry (CPB 0710, reviewed 2025-10-14)

Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy

20-947 Medical Policies - 3rd Quarter 2020

20-944 Medical Policies - 3rd Quarter 2020

20-946 Medical Policies - 3rd Quarter 2020

What insurance policy changes affect code G40.001?

Which payers have updated policy for code G40.001?

How do I get notified when code G40.001 policy changes?

Why do payers change policies for code G40.001?