ICD-10 G40.119 is officially defined as "Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus." code G40.119 is referenced in 9 tracked payer policy changes from Independence Blue Cross, Nevada Medicaid, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code G40.119 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Independence Blue Cross Medicare Advantage has added four new CPT codes (1057T, 1058T, 1059T, 1060T, 1061T) to policy MA11.019n effective 10/01/2026, classified as Experimental/Investigational for vagus nerve stimulation. These codes are NOT covered and should not be billed to Medicare Advantage plans. The policy maintains coverage only for medically refractory seizures under specific criteria.
Nevada Medicaid now allows billing for vagus nerve stimulation (VNS) therapy device codes C1767 and C1778 for refractory epilepsy treatment by outpatient surgery centers, hospitals, and ambulatory surgical centers. These devices will be reimbursed at 82% of acquisition cost and require prior authorization plus specific refractory epilepsy diagnosis codes.
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 covers cerebral hemispherectomy, corpus callosotomy and temporal lobectomy (including selective amygdalohippocampectomy) when the selection criteria are met, and considers them experimental, investigational or unproven when those criteria are not met. Responsive cortical stimulation for adults with intractable focal aware or focal impaired awareness seizures is covered when its listed criteria are met, and Aetna considers responsive cortical stimulation experimental for primary generalized seizures and all other indications. Deep brain stimulation for members with intractable seizures is covered when the medical necessity criteria in CPB 0208 are met. Aetna considers stereotactic radiosurgery for small-volume hypothalamic hamartomas with intractable epilepsy in children medically necessary when the hamartoma is less than 3 cm3 and the area of fusion with the hypothalamus is less than 150 mm2. Magnetic resonance-guided laser interstitial thermal therapy is an alternative to standard surgery where the epilepsy surgery criteria are met, and the Wada test is considered medically necessary. Aetna considers stereotactic radiosurgery for medial temporal lobe epilepsy, chronic pulvinar stimulation, AI-assisted localization for epileptogenic zones, subpial transection surgery, hippocampal electrical stimulation and trigeminal nerve stimulation experimental, investigational or unproven.
Functional MRI of the brain may be considered medically necessary as a complementary test in the preoperative evaluation of individuals with refractory epilepsy or brain tumors who are candidates for neurosurgery when the lesion is in close proximity to an eloquent area of the brain (for example, one controlling verbal or motor function) and testing is expected to have an important role in assessing the spatial relation between the lesion and the eloquent brain area. Functional MRI is considered investigational for all other applications. The 01/31/2025 policy update changed the title to add presurgical mapping or seizure focus localization and changed the medical policy number to L.6.01.423, with the policy statements unchanged.
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.
Magnetoencephalography (MEG) and magnetic source imaging (MSI) may be considered medically necessary for determining the laterality of language function as a substitute for the Wada test in patients preparing for surgery for epilepsy, brain tumors, and other indications requiring brain resection. MEG/MSI may also be considered medically necessary as part of the preoperative evaluation of patients with drug-resistant epilepsy (seizures refractory to at least two first-line anticonvulsants) when standard techniques such as MRI and EEG do not provide satisfactory localization of epileptic lesion(s). MEG/MSI is considered investigational for all other indications.
FDG-PET for individuals with epileptic seizures who are candidates for surgery may be considered medically necessary, and so may FDG-PET for the diagnosis of chronic osteomyelitis. The use of FDG-PET for all other miscellaneous indications is investigational, including a long list of central nervous system, pulmonary, and musculoskeletal conditions. This policy does not cover oncologic, cardiovascular, or Alzheimer disease or other dementia uses of FDG-PET, which are addressed in related policies.
Vagus nerve stimulation is considered medically necessary as a treatment of medically refractory seizures, defined as seizures that occur despite therapeutic levels of antiepileptic drugs, or seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse events of these drugs. It is considered investigational for depression, heart failure, upper-limb impairment due to stroke, essential tremor, headaches, rheumatoid arthritis, fibromyalgia, tinnitus and traumatic brain injury, including but not limited to these conditions, and transcutaneous (nonimplantable) vagus nerve stimulation devices are investigational for all indications. The 05/21/2026 update changed the policy statement to say vagus nerve stimulation is considered investigational as a treatment of rheumatoid arthritis, and removed ICD-9 procedure and diagnosis codes from the code reference.
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