HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 
Medical Policy:
M-61-010
Topic:
Autonomic Nervous System Function Testing
Section:
Diagnostic Medical
Effective Date:
November 26, 2018
Issued Date:
July 22, 2019
Last Revision Date:
June 2019
Annual Review:
June 2019
 
 

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.

Policy Position

ANS testing, consisting of a battery of tests in several domains, may be considered medically necessary when ALL 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 tests, 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

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

95921

95922

95923

95924

95943

 

 


ANS testing is considered experimental/investigational (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 psychologic 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)

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.

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

 


Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Autonomic Nervous System Function Testing is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.