Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Autonomic function testing, consisting of a battery of tests in several domains may be considered medically necessary when used as a diagnostic tool to evaluate symptoms indicative of vasomotor instability, such as hypotension, orthostatic tachycardia, and hyperhidrosis after more common causes have been excluded by other testing. ANS testing is directed at establishing a more accurate or definitive diagnosis or contributing to clinically useful and relevant medical decision making for one (1) or more of the following indications:
- To diagnose the presence of autonomic neuropathy in an individual with signs or symptoms suggesting autonomic neuropathy or to evaluate the severity and distribution of a diagnosed autonomic neuropathy in the following conditions:
-
Amyloid neuropathy;
or
-
Diabetic autonomic neuropathy;
or
-
Idiopathic neuropathy;
or
-
Multiple system atrophy (Shy-Drager syndrome
); or
-
Pure autonomic failure;
or
-
Sjogren's syndrome;
or
-
Reflex sympathetic dystrophy (i.e., sympathetically maintained pain/causalgia);
or
-
To differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of consciousness;
or
-
To evaluate inadequate response to beta blockade in vasodepressor syncope;
or
-
To evaluate distressing symptoms in an individual with a clinical picture suspicious for distal small fiber neuropathy in order to diagnose the condition;
or
-
To differentiate the cause of postural orthostatic tachycardia syndrome;
or
-
To evaluate change in type, distribution or severity of autonomic deficits in individuals with autonomic failure;
or
-
To evaluate the response to treatment in individuals with autonomic failure who demonstrate a change in clinical exam;
or
-
To diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic individual;
or
- To evaluate and treat individuals with recurrent unexplained syncope to demonstrate autonomic failure, after more common causes have been excluded by other standard testing.
ANS testing is considered not medically necessary for the following conditions:
-
Allergic conditions;
or
-
Anxiety and other psychologic disorders;
or
-
Chronic fatigue syndrome;
or
-
Detoxification/relaxation;
or
-
Fibromyalgia;
or
-
Hypertension;
or
-
Monitoring progression of disease or response to treatment;
or
-
Screening of asymptomatic individuals;
or
- Sleep apnea.
Although there is no standard battery of tests for ANS testing, a full battery generally consists of individual tests in three (3) categories:
-
Cardiovagal function (heart rate variability, heart rate response to deep breathing and Valsalva maneuver);
or
-
Sudomotor function (quantitative sudomotor axon reflex test, quantitative sensory test, thermoregulatory sweat test, silastic sweat imprint, sympathetic skin response, electrochemical sweat conductance);
or
- Vasomotor adrenergic function (blood pressure response to standing, Valsalva maneuver, hand grip, and tilt table testing)
NOTE: At least one (1) test in each category is usually performed. More than one (1) test from a category will often be included in a battery of test, but the incremental value of using multiple tests in a category is unknown.
The following tests are considered not medically necessary:
-
Autonomic nervous system testing using portable automated devices (i.e., ANSAR® test, Sudoscan);
or
-
Cold pressor test;
or
-
Gastric emptying tests;
or
-
Plasma catecholamine levels;
or
-
Pupillography;
or
-
Pupil edge light cycle;
or
-
Quantitative direct and indirect testing of sudomotor function test;
or
- Skin vasomotor testing.
ANS testing not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
