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Autonomic Nervous System Function Testing

Effective Date: September 01, 2019
Revised Date: August 02, 2019

Description

Autonomic Nervous System (ANS) 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.

Criteria

ANS testing, consisting of a battery of tests in several domains may be considered medically necessary when ALL of the following criteria are met: 

  • Signs and/or symptoms of autonomic dysfunction are present; and
  • A definitive diagnosis cannot be made from clinical examination and routine laboratory testing alone; and
  • Diagnosis of the suspected autonomic disorder will lead to a change in management or will eliminate the need for further testing. 

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) 
  • Vasomotor adrenergic function (blood pressure response to standing, Valsalva maneuver, hand grip, and tilt table testing) 
  • Sudomotor function (Quantitative Sudomotor Axon Reflex Test, quantitative sensory test, Thermoregulatory Sweat Test, silastic sweat imprint, sympathetic skin response, electrochemical sweat conductance) 

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: 

  • Pupil edge light cycle 
  • Gastric emptying tests 
  • Cold pressor test 
  • Quantitative direct and indirect testing of sudomotor function test 
  • Plasma catecholamine levels 
  • Skin vasomotor testing

Procedure Codes

95921 95922 95923 95924 95943

ANS testing is considered experimental/investigation (E/I) and therefore non-covered for the following conditions because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature: 

  • Chronic fatigue syndrome 
  • Quantitative pupillometry 
  • Fibromyalgia 
  • Anxiety and other psychological disorders 
  • Sleep apnea 
  • Allergic conditions 
  • Hypertension 
  • Screening of asymptomatic individuals 
  • Monitoring progression of disease or response to treatment 
  • Detoxification/relaxation 
  • Autonomic nervous system testing using portable automated devices (e.g., ANSAR test)

ANS testing not meeting the above criteria is considered not medically necessary.

Procedure Codes

95999 0341T

ANS testing should be performed in a dedicated ANS testing laboratory. Testing in a dedicated laboratory should be performed under closely controlled conditions, and results should be interpreted by an individual with expertise in ANS testing. Testing using automated devices with results interpreted by computer software has not been validated and thus has the potential to lead to erroneous results.

Diagnoses Codes

Covered Diagnosis Codes for procedure codes 95921, 95922, 95923, 95924, and 95943. 

E10.40 E10.41 E10.42 E10.43 E10.44 E10.49 E10.610
E11.40 E11.41 E11.42 E11.43 E11.44 E11.49 E11.610
E13.40 E13.41 E13.42 E13.43 E13.44 E13.49 E13.610
E85.0 E85.1 E85.2 E85.3 E85.4 E85.81 E85.82
E85.89 E85.9 G23.0 G23.1 G23.2 G23.8 G23.9
G60.0 G60.3 G60.8 G60.9 G61.0 G61.1 G61.81
G61.89 G90.09 G90.2 G90.3 G90.4 G90.50 G90.511
G90.512 G90.513 G90.519 G90.521 G90.522 G90.523 G90.529
G90.59 G90.9 I95.1 M35.04 R00.0 R55

 

Links

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  1. Keet SWM, Bulte CSE, Sivanathan A, et al. Cardiovascular autonomic function testing under nonstandardised and standardised conditions in cardiovascular patients with type-2 diabetes mellitus. Anesthesia. 2014; 69: 476–483.
  2. Connelly MA, Brown JT, Kearns GL, et al. Pupillometry: A non-invasive technique for pain assessment in pediatric patients. Arch Dis Child. 2014; 99(12): 1125-1131.
  3. Johnson EL, Miller Singley AT, Peckham AD, et al. Task-evoked pupillometry provides a window into the development of short-term memory capacity. Front Psychol. 2014; 5(218).
  4. Lerner AG, Bernabé-Ortiz A, Ticse R, et al. Type 2 diabetes and cardiac autonomic neuropathy screening using dynamic pupillometry [abstract]. Diabet Med. April 7, 2015.
  5. American Diabetes Association. Standards of medical care in diabetes--2014. Diabetes Care. 2014;31(1):S17-S80. http://care.diabetesjournals.org. Accessed on 5/5/2015.
  6. Gibbons DH, Cheshire Jr. WP, Fife TD. American Academy of Neurology (AAN) Model coverage policy: Autonomic testing. 2014.
  7. American Association of Neuromuscular and Electrodiagnostic Medicine. Proper Performance of Autonomic Function Testing. Muscle & Nerve. 2017; 55: 3-4.
  8. Olsen S. Impaired Awareness of Hypoglycemia in Adults With Type 1 Diabetes Is Not Associated With Autonomic Dysfunction or Peripheral Neuropathy. Diabetes Care. 2016;39: 426-433.
  9. American Association of Neuromuscular & Electrodiagnostic Medicine. Proper Performance of Autonomic Function Testing. 2017.
  10. Chelimsky G, McCabe NP, Janata J, Elston R, Zhang, et al. Autonomic testing of women with interstitial cystitis/bladder pain syndrome. Clin Auton Res. 2014; 24: 161-166.
  11. Yuan T, Li J, Fu Y, Xu T, Li J, Wang X, et al. A cardiac risk score based on sudomotor function to evaluate cardiovascular autonomic neuropathy in asymptomatic Chinese patients with diabetes mellitus. PLoS ONE. 2018;13(10): e0204804.https://doi.org/10.1371/journal.pone.0204804, accessed 5/29/2019.
  12. Huang F, Xu C, Deng X Zuo P, Lin F, Fan J, et al. Deceleration Capacity A Novel Measure for Autonomic Nervous System in Patients with Vasovagal Syncope on tilt-table Testing. J Huazhong Univ Sci Technol. 2017;37(3):326-331.
  13. Pertab J, Merkley T, Cramond A, Cramond K, Paxton H, Wu T. Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review. Neuro Rehab. 2018; 42:397-427.