Indications

Autonomic nervous system (ANS) function testing (95921, 95922, 95923) is eligible to be performed one time in order to diagnose (confirm or exclude) specific autonomic neuropathy or disease and determine its degree of progression.  For patients with diagnosed autonomic disorders, the eligibility of repeated testing is governed by a change in clinical status or response to a therapeutic intervention.  Monitoring of disease progression with ANS testing is only eligible when there has been a change in clinical status, or for evaluation of a patient’s response to directed treatment of a specific autonomic disorder. 

Autonomic nervous system function testing is eligible when performed in an academic testing center or an accredited autonomic testing laboratory when used for the following reasons/indications:

• Diagnose the presence of suspected progressive autonomic neuropathy and determine its severity and distribution
  
  
• Diagnose suspected axonal neuropathy in symptomatic patients
  
  
• Differentiate between benign and life-threatening autonomic disorders (e.g., chronic idiopathic anhidrosis vs. adrenergic and cardiovagal failure, or syncope vs. peripheral autonomic failure)
  
  
• Diagnose suspected distal small fiber neuropathy
  
  
• Perform a postural evaluation of tachycardia syndrome
  
  
• Diagnose sympathetically maintained pain (e.g., reflex sympathetic dystrophy or causalgia)
  
  
• Monitor the course or progression of diagnosed autonomic failure.  ANS testing is indicated initially to diagnose autonomic failure.  Monitoring may be indicated when the autonomic deficits change in type, distribution, or severity.
  
  
• Evaluate the response of diagnosed autonomic failure to treatment, and determine whether the autonomic deficits have lessened in response to treatment.
  
  
• To aid in the differential diagnosis of recurrent syncope that poses a management problem or requires a tilt study and autonomic screening to evaluate the response to treatment.

Limitations

Autonomic nervous system function testing is considered not medically necessary for the following:

• To screen patients without signs or symptoms of autonomic dysfunction or to test for the sole purpose of monitoring disease intensity or treatment efficacy (i.e., diabetes, renal disease). 
  
  
• When performed in a physician’s office using noninvasive digital autonomic nervous system testing devices (e.g., ANSAR ANX 3.0). 
  
  
• Routine monitoring of the course or progression of diagnosed autonomic failure where there are no changes in type, distribution or severity of deficits.
  
  
• ANS function testing is not considered medically necessary unless the results of the testing are to be used in clinical decision making and patient management. 

The use of detoxification/relaxation devices that utilize vibration, sound, lights, and frequency (e.g., Life Vessel) to "balance," detoxify or de-stress the autonomic nervous system are also considered not medically necessary.

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary.  A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement should be maintained in the provider's records. 

Description

Autonomic nervous system function tests are generally indicated to diagnose a condition, to provide unique differential diagnostic information, or to quantify those aspects of autonomic function that have an impact on outcome or evaluate treatment efficacy.  Autonomic nervous system function testing consists of a battery of calibrated tests that provide an accurate assessment of the status of different parts of the autonomic nervous system.  Appropriate selection and interpretation of autonomic tests requires significant knowledge, training, and expertise.

The selection of a specific test requires a detailed knowledge of the testing criterion and a match between the tests of suspected clinical/functional impairment with the autonomic activity being tested.  Most autonomic disorders are diagnosed clinically, with laboratory and formal diagnostic testing playing an adjunctive or confirmatory role. 

The role of autonomic testing in a patient suspected of having a progressive autonomic neuropathy is to diagnose the presence of autonomic neuropathy and determine its severity, involvement by autonomic system (cardiovagal, adrenergic, sudomotor) distribution, and level (pre- versus post-ganglionic).  The aim of such testing is to correlate signs and symptoms of possible autonomic dysfunction with objective measurement in a way that is clinically useful. 

Autonomic nervous system testing can be grouped into three general categories:

1. Cardiovagal Innervation Tests (95921) – Provide a standardized quantitative evaluation of vagal innervation to the heart (parasympathetic function).  The responses are based on the interpretation of changes in continuous heart rate recordings in response to standardized maneuvers and include the following: heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio heart rate response to standing.
   
   
2. Vasomotor Adrenergic Innervation (95922) – Evaluates adrenergic innervation of the circulation and of the heart in autonomic failure.  The following tests are included: beat-to-beat blood pressure and R-R interval response to Valsalva maneuver, sustained hand grip, and blood pressure and heart rate responses to tilt-up or active standing.
   
   
3. Sudomotor Function (95923) can be evaluated using any of the following methods:

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

American Academy of Neurology. Assessment: Clinical autonomic testing report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 1996; 46(3):873-880

Barthelemy JC, Pichot B, Dauphinot V, et al. Autonomic nervous system activity and decline as prognostic indicators of cardiovascular and cerebrovascular events: the 'PROOF' study.  Study design and population sample. Associations with sleep-related breathing disorder: the 'SYNAPSE' study.  Neuroepidemiology. 2007; 29 (1-2):18-28.

Park SB, Lee BC, Jeong KS. Standardized tests of heart rate variability for autonomic tests in healthy Koreans. Int J Neurosci. 2007; 117(12):1707-1717.

Bauer A, Malik M, Schmidt G, et al. Heart rate turbulence: standards of measurement, physiological interpretation, and clinical use: International Society for Holter and Noninvasive Electrophysiology Consensus. J Am Cardiol. 2008; 52(17):1353-65.

England JD, Gronseth GS, Franklin G., et al.  Practice parameter: Evaluation of distal symmetric polyneuropathy: Role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review).  Neurology. 2009; 72(2): 177-84.