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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-95805-20

Original Effective Date: 03/15/15

Reviewed: 07/27/17

Revised: 08/15/17

Next Review: 07/26/18

Subject: Autonomic Nervous System Testing

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

The autonomic nervous system (ANS) controls physiologic processes that are not under conscious control. ANS disorders, also called dysautonomias, are heterogeneous in etiology, clinical symptoms, and severity. ANS disorders can be limited and focal, such as patients with isolated neurocardiogenic syncope or idiopathic palmar hyperhidrosis. At the other extreme, some ANS disorders can be widespread and severely disabling, such as patients with multiple systems atrophy, which leads to widespread and severe autonomic failure.

ANS testing consists of a battery of individual tests that evaluate the integrity and function of the ANS. These tests are intended to be adjuncts to the clinical examination in the diagnosis of ANS disorders. ANS testing is typically performed in a dedicated ANS testing laboratory in patients with signs and symptoms of autonomic dysfunction. Testing in a laboratory should be performed under closely controlled conditions, and interpretation of the results should be performed by an individual with expertise in ANS testing. Testing using automated devices with interpretation of the results performed by computer software has not been validated and thus has the potential to lead to erroneous results.

POSITION STATEMENT:

Autonomic nervous system (ANS) testing, consisting of a battery of tests in several domains, meets the definition of medical necessity when ALL of the following criteria are met:

a) Signs and/or symptoms* of autonomic dysfunction are present; AND

b) A definitive diagnosis cannot be made from clinical examination and routine laboratory testing alone; AND

c) Diagnosis of the suspected autonomic disorder will lead to a change in management or will eliminate the need for further testing.

Note: Although there is not a standard battery of tests that are part of ANS testing, a full battery of testing generally consists of individual tests in three categories: 1. Cardiovagal function (heart rate [HR] variability, HR response to deep breathing and Valsalva); 2. Vasomotor adrenergic function (blood pressure [BP] response to standing, Valsalva, and hand grip, tilt table testing); 3. Sudomotor function (QSART, QST, TST, silastic sweat test, sympathetic skin response, electrochemical sweat conductance). At least one test in each category is usually performed. More than one test from a category will often be included in a battery of tests, but the incremental value of using multiple tests in a category is not known.

*(Symptoms of autonomic disorders can be varied, based on the etiology and location of dysfunction. Cardiovascular manifestations are often prominent. Involvement of the cardiovascular system causes abnormalities in heart rate control and vascular dynamics. Orthostatic hypotension and other manifestations of BP lability can occur, causing weakness, dizziness, and syncope. Resting tachycardia and an inability to appropriately increase heart rate in response to exertion leads to exercise intolerance.)

Autonomic nervous system testing is considered experimental or investigational in all other situations when criteria are not met, including but not limited to the evaluation of the following conditions, as there is a lack of direct evidence on changes in management or health outcomes:

• chronic fatigue syndrome

• fibromyalgia

• anxiety and other psychological disorders

• sleep apnea

• allergic conditions

• hypertension

• screening of asymptomatic individuals

• monitoring progression of disease or response to treatment.

The following tests are generally considered to have uncertain value in ANS testing and are considered experimental or investigational when used in ANS testing:

• Pupillography

• Pupil edge light cycle

• Gastric emptying tests

• Cold pressor test

• QDIRT test

• Plasma catecholamine levels

• Skin vasomotor testing

• The ANSAR® test.

Autonomic nervous system testing using portable automated devices is considered experimental or investigational for all indications. These devices have not been validated and have a greater potential to lead to erroneous results.

BILLING/CODING INFORMATION:

CPT Coding:

95921

Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio

95922

Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt

95923

Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential

95924

Testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt

95943

Simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic function, based on time-frequency analysis of heart rate variability concurrent with time-frequency analysis of continuous respiratory activity, with mean heart rate and blood pressure measures, during rest, paced (deep) breathing, Valsalva maneuvers, and head-up postural change (Investigational)

0341T

Quantitative pupillometry with interpretation and report, unilateral or bilateral (Investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline review date: Autonomic Function Tests (L33609) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Nerve Conduction Studies; F-Wave Studies; H- Reflex Studies, 01-95805-02
Evoked Potentials, Intraoperative Neurophysiologic Testing, and Quantitative Electroencephalography (QEEG), 01-95805-13

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Neurology AAoNaEM, American Academy of Physical Medicine and Rehabilitation. Practice parameter: evaluation of distal symmentric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review) (2013), accessed at neurology.com 01/24/16.
  2. American Association of Neuromuscular Electrodiagnostic Medicine. Proper performance of autonomic function testing. Muscle Nerve. Jan 2017;55(1):3-4.
  3. Blue Cross Blue Shield Association Medical Policy Reference Manual, 2.01.96 Autonomic Nervous System Testing, 06/17.
  4. ClinicaTrials.gov, Assessment of Small Fiber Neuropathy in Rare Diseases Using Sudoscan, sponsored by Massachusetts General Hospital, accessed 06/13/17.
  5. ClinicalTrials.gov, Cutaneous Autonomic Pilomotor Testing to Unveil the Role of Neuropathy Progression in Early Parkinson's Disease (CAPTURE PD), sponsored by GWT-TUD GmbH, accessed 06/13/17.
  6. ClinicalTrials.gov, SudoScan as a Biomarker of Parkinson's Disease, sponsored by McGill University Health Center, accessed 06/13/17.
  7. European Federation of Neurological Societies. Guideline: Orthostatic Hypotention (2011).
  8. First Coast Service Options, Inc. (FCSO), LCD for Autonomic Function Tests (L33609), 10/01/15; accessed at fcso.com 6/13/17.
  9. Gibbons CH, Cheshire WP, Fife TD. American Academy of Neurology Model Coverage Policy: Autonomic Nervous System Testing. 2014; accessed at aan.com 6/13/17.
  10. Lahrmann H, Cortelli P, Hilz M, Mathias CJ, Struhal W, Tassinari M. Orthostatic hypotension. In: Gilhus NE, Barnes MP, Brainin M, editor(s). European handbook of neurological management. 2nd ed. Vol. 1. Oxford (UK): Wiley-Blackwell; 2011. p. 469-75.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/27/17.

GUIDELINE UPDATE INFORMATION:

03/15/15

New Medical Coverage Guideline; formatting changes.

03/15/16

Annual review; program exception and references updated.

08/15/17

Annual review; position statements maintained and references updated; formatting changes.

Date Printed: October 20, 2017: 08:42 AM