HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
M-61-020
Topic:
Autonomic Nervous System Function Testing
Section:
Diagnostic Medical
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
May 2022
 
 

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 that 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

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 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
    • Sjoren'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 tests, 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. 

95921

95922

95923

95924

   

 




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, and 95924

E08.40

E08.41

E08.42

E08.43

E08.49

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

G23.3

G23.8

G23.9

G57.71

G57.72

G57.73

G58.7

G60.0

G60.2

G60.3

G60.8

G60.9

G61.0

G61.1

G61.81

G61.82

G61.89

G61.9

G90.A

G90.01

G90.09

G90.1

G90.2

G90.3

G90.4

G90.511

G90.512

G90.513

G90.521

G90.522

G90.523

G90.8

G90.9

G99.0

I47.11

I47.19

I49.8

I95.0

I95.1

I95.9

I99.8

K31.84

L74.4

M32.0

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M32.8

M32.9

M35.00

M35.01

M35.02

M35.03

M35.04

M35.05

M35.06

M35.07

M35.08

M35.09

M35.0A

M35.0B

M35.0C

R00.9

R03.1

R42

R00.0

R55

R61

R68.89

 

 



Place of Service: Inpatient/Outpatient

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.

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.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





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.