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.
ANS testing, consisting of a battery of tests in several domains may be considered medically necessary when ALL of the following criteria are met:
Although there is no standard battery of tests for ANS testing, a full battery generally consists of individual tests in three (3) categories:
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:
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:
ANS testing not meeting the above criteria is considered not medically necessary.
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.
Covered Diagnosis Codes for procedure codes 95921, 95922, 95923, 95924, and 95943.
Internal Medical Policy Committee 3-16-2020 Coding update only
Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.