Commercial
Advanced Search

Autonomic Nervous System Testing
07.03.23g

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

MEDICALLY NECESSARY

Autonomic nervous system (ANS) testing is considered medically necessary and, therefore, covered when either of the following indications is met:
  • ANS testing is being used as a diagnostic tool to evaluate symptoms indicative of vasomotor instability (e.g., hypotension, postural tachycardia, hyperhidrosis) after more common causes have been excluded by other testing.
OR
  • ANS testing is contributing to clinical decision-making for any of the following indications:
    • To evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy
    • To differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of consciousness
    • To evaluate inadequate response to beta blockade in vasovagal syncope
    • To evaluate distressing symptoms suggestive of distal small fiber neuropathy
    • To differentiate the cause of postural tachycardia syndrome
    • To evaluate change in type, distribution, or severity of autonomic deficits in individuals with autonomic failure
    • To evaluate the response to treatment in individuals with autonomic failure who demonstrate a change in clinical exam
    • To diagnose axonal neuropathy or suspected autonomic neuropathy
    • To evaluate and treat individuals with recurrent unexplained syncope to demonstrate autonomic failure after more common causes have been excluded by other standard testing
    • To evaluate the level of autonomic system dysfunction in distal symmetric polyneuropathy of diabetes when other standard testing yields inconclusive or atypical test results, including:
      • Greater motor than sensory nerve involvement
      • Asymmetry
      • Rapid progression of polyneuropathy
    • To diagnose cardiovascular autonomic neuropathy of diabetes and determine its severity and distribution
NOT MEDICALLY NECESSARY

ANS testing is considered not medically necessary and, therefore, not covered for any of the following indications:
  • Screening of individuals who are without signs or symptoms of autonomic dysfunction, including individuals with diabetes, hepatic disease, or renal disease
  • Testing for the sole purpose of monitoring disease intensity or treatment efficacy in individuals with diabetes, hepatic disease, or renal disease
  • Testing when the results will not be used for clinical decision-making and management of an individual
  • Testing to diagnose acute motor axonal neuropathy (AMAN)
NOT COVERED

Testing performed by professional providers who are not trained and are without the expertise to perform and interpret these tests is not covered.

ANS testing using devices such as SUDOSCAN or “ESC” (electrochemical skin conductance), ANSAR ANX 3.0, and similar devices do not meet the definition of sudomotor function testing in that the subject preparation, environmental requirements, and specially trained medical personnel requirements are not met. Therefore, they are ​not covered and, therefore, not eligible for reimbursement consideration.

BILLING REQUIREMENTS

ANS testing using SUDOSCAN​, ESC, ANSAR ANX 3.0, and similar devices do not meet the definition of CPT code 95923 in that the subject preparation, environmental requirements, and specially trained medical personnel requirements are not met.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Most autonomic nervous system (ANS) testing is performed in a laboratory with formal diagnostic testing for clinical diagnosis of an ANS disorder.

Testing may be appropriate to monitor disease progression when there is a change in the individual's clinical status, or to evaluate the individual's response to a specific treatment for an autonomic disorder.

Frequency of testing depends on changes in clinical status or response to intervention.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, ANS testing is covered under the medical benefits of Company’s products when medical necessity criteria in the medical policy are met.

However, services that are identified in this policy as not medically necessary or experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

The autonomic nervous system (ANS) is a complex neural regulatory network that controls involuntary visceral actions. The ANS regulates physiologic processes, such as blood pressure, heart rate, body temperature, digestion, metabolism, fluid and electrolyte balance, sweating, urination, defecation, sexual response, and other processes. Regulation occurs without conscious control, i.e., autonomously. The ANS is subdivided into two systems, the parasympathetic and sympathetic systems, that work together to maintain equilibrium of physiologic processes within the body.

The parasympathetic nervous system controls the physiological processes that control and store energy, often called the "rest and digest" system. The parasympathetic system, which is primarily involved with catabolic processes, conserves energy as it slows the heart rate, increases intestinal and gland activity, increases splanchnic circulation, and relaxes sphincter muscles in the gastrointestinal tract. As a counterbalance, the sympathetic nervous system is responsible for arousal, and is known as the "fight-or-flight" response. Stimulation of the sympathetic nervous system results in an increase in pulse and blood pressure, increased sweating, decreased gastrointestinal motility, increased synthesis of important metabolic products for energy expenditure, and increase in glandular exocrine secretions. It also causes sweaty palms, and less immediate life-preserving functions (e.g., digestion, renal filtration) are decreased.

Disorders of the ANS can affect any system of the body. They can originate in the peripheral or central nervous system and may be primary or secondary to other disorders. Symptoms suggesting autonomic dysfunction include orthostatic hypotension, heat intolerance, nausea, constipation, urinary retention or incontinence, nocturia, impotence, and dry mucous membranes. If an individual has symptoms suggesting autonomic dysfunction, cardiovagal, adrenergic, and sudomotor tests are usually done to help determine severity and distribution of the dysfunction.

Drugs can have substantial effects on the results of ANS testing and are a common cause of falsely abnormal results. Individuals should refrain from caffeine, nicotine, and alcohol at least 3 hours prior to testing. All medications with adrenergic and anticholinergic properties need to be discontinued at least 48 hours prior to the study. These would include, but are not limited to, the following drugs: chlorpromazine, thioridazine, the tricyclic and tetracyclic antidepressants, bupropion, mirtazapine, venlafaxine, clonidine, alpha-blockers, beta-blockers, calcium channel blockers, opiates, topical capsaicin, and diphenhydramine.

ANS testing consists of a battery of tests intended to evaluate the integrity and function of the ANS. As most of the ANS is inaccessible to testing, the available tests are measures of end-organ response rather than direct measures of ANS function. The aim of such testing is to correlate signs and symptoms of possible autonomic dysfunction with objective measurement in a way that is clinically useful. There are numerous individual tests of ANS function, and a combination of them is typically used in ANS testing. ANS testing can be grouped into three general categories:

Cardiovagal innervation: Provides a standardized quantitative evaluation of vagal innervation to parasympathetic function of the heart. Responses are based on the interpretation of changes in continuous heart recordings in response to standardized maneuvers and include heart rate (HR) response to deep breathing, Valsalva ratio, and 30:15 ratio heart rate responses to standing. Reduced, or absent, heart rate variability is a sign of autonomic dysfunction.
  • Heart rate response to deep breathing: The most widely used test, and considered by some as the optimal test, of cardiovagal function. This test measures the maximal HR variability during deep breathing (6 breaths/min) in the laboratory setting, where the confounding variables of age, rate, and depth of respiration are controlled.
  • Valsalva ratio: This test measures the ratio derived from the maximal HR generated by the Valsalva maneuver divided by the lowest HR following the maneuver.
  • Heart rate response to standing: This index of cardiovagal function measures the normal tachycardia and bradycardia associated with proper baroreflex function while moving from sitting to standing. The test provides information to calculate the 30:15 ratio (R-R interval at beat 30)/(R-R interval at beat 15).
Vasomotor adrenergic innervation: Evaluates adrenergic sympathetic innervation of the circulation and of the heart in autonomic failure. The following tests are included: beat-to-beat blood pressure (BP) and R-R interval response to Valsalva maneuver, BP and HR response to active standing, tilt table testing, and sustained hand grip.
  • Beat-to-beat BP recordings of the Valsalva maneuver: This test records blood pressure changes in response to the different stages of the Valsalva maneuver, for comparison to age- and sex-standardized values.
  • BP and HR response to standing: This test is a recording of BP change when the patient shifts from supine to standing position, for comparison to age- and sex-standardized values.
  • Tilt-table testing: This test evaluates for orthostatic intolerance. The patient lies on the table and is strapped in with a foot rest. The table is then inclined to the upright position, with monitoring of the pulse and BP. Symptoms of lightheadedness or syncope in conjunction with changes in pulse or BP constitute a positive test. A provocative medication, such as isoproterenol, can be given to increase the sensitivity of the test.
  • Sustained hand grip: This test measures blood pressure response to sustained handgrip, in which continual muscle contraction causes a rise in systolic and diastolic BP and HR. Efferent fibers travel to the muscle and heart, resulting in increased cardiac output, BP, and HR. Abnormal values indicate sympathetic damage.
Sudomotor function testing: Evaluates and documents neuropathic disturbances that may be associated with pain. The quantitative sudomotor axon reflex test (QSART), thermoregulatory sweat test (TST), sympathetic skin responses, and silastic sweat imprints are tests of sympathetic cholinergic sudomotor function.
  • QSART: This test measures axon reflex–​mediated sudomotor responses quantitatively and evaluates postganglionic sudomotor function. Recording is usually carried out from the forearm and three lower extremity skin sites to assess the distribution of postganglionic deficits.
  • TST: This test evaluates the distribution of sweating by a change in color of an indicator powder. This test has a high sensitivity, and its specificity for delineating the site of lesion is greatly enhanced when used in conjunction with QSART. Sweat imprints are formed by the secretion of active sweat glands into a plastic (silastic) imprint. The test can determine sweat gland density, a histogram of sweat droplet size, and sweat volume per area.
  • Sympathetic skin response tests: These tests use an electric current to stimulate sympathetic nerves in order to measure the change in electrical resistance, which is altered in the presence of sweat.
  • Silastic sweat imprints: This test is used to determine sweat gland density, sweat droplet size, and sweat volume per area. Silicone-based plastic material is placed on the skin, and the droplets from active sweat glands form indentations on the surface, allowing quantitation of the degree of sweating present.
ANS TESTING DEVICES

Several ANS testing devices have been cleared for marketing since 1976. The ANSAR ANX 3.0 is a noninvasive, real-time digital ANS monitor. The ANSAR ANX 3.0 received FDA approval in 2004, and is being promoted as a device that measures both branches of the ANS (the sympathetic and the parasympathetic) independently and simultaneously in real-time. The ANSAR ANX 3.0 performs respiratory-based digital testing of the ANS and heart rate variability measurements.

Another device, SUDOSCAN or electrochemical skin conductance (ESC) test, consists of two sets of large-area stainless steel electrodes for the hands and feet that are connected to a computer for recording and for data-management purposes. SUDOSCAN, cleared for marketing in 2010, is a noninvasive device being marketed for the early detection of small nerve fibers and to help define and monitor a treatment to improve and control complications such as peripheral neuropathy, which is caused by type 2 diabetes.

Devices such as ANSAR ANX 3.0, SUDOSCAN, and similar devices are being used for screening purposes and do not require special preparation of the individual or specially trained medical personnel to operate. The use of automated devices, with interpretation of the results by computer software, has not been validated and has the potential for invalid results.

References

Abi-Samra F, Maloney JD, Fouad-Tarazi FM, et al. The usefulness of head-up tilt testing and hemodynamic investigations in the workup of syncope of unknown origin. Pace.1988;11:1202-1214.

American Academy of Neurology. Assessment: clinical autonomic testing report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 1996;46(3):873-880.

American Association of Neuromuscular Electrodiagnostic Medicine. Proper performance of autonomic function testing. Muscle Nerve. 2017;55(1):3-4.


American Association of Neuromuscular & Electrodiagnostic Medicine. 2023; https://www.aanem.org/Advocacy/Position-Statements/Recommended-Policy-for-Electrodiagnostic-Medicine. Accessed March 27, 2024.

American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Position statement: proper performance of autonomic function testing. January 2023. Available at: https://www.aanem.org/clinical-practice-resources/position-statements/position-statement/recommended-policy-for-electrodiagnostic-medicine. Accessed March 27, 2024.


American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Recommended Policy for Electrodiagnostic Medicine. May 2017. Available at: https://www.aanem.org/docs/default-source/documents/aanem/advocacy/proper-performance-of-autonomic-function-testing_final.pdf?sfvrsn=a37c1845_1. Accessed March 27, 2024.

​

American Diabetes Association. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S135-S151.

Bellavere F, Ragazzi E, Chilelli NC, et al. Autonomic testing: which value for each cardiovascular test? An observational study. Acta Diabetol. 2019;56(1):39-43.

Benditt D. Reflex syncope in adults and adolescents: clinical presentation and diagnostic evaluation. [UpToDate Web site]. 04/18/2022. Available at: https://www.uptodate.com/contents/reflex-syncope-in-adults-and-adolescents-clinical-presentation-and-diagnostic-evaluation?search=vasodepressor syncope&source=search_result&selectedTitle=1~114&usage_type=default&display_rank=1 [via subscription only]. Accessed March 27, 2024.

Benditt DG, Maloney JD, Ferguson DW, et al. ACC expert consensus document: tilt table testing for assessing syncope. J Am Coll Cardiol. 1996;28(1):263-275.

Brignole M, Alboni P, Benditt D, et al. Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J. 2001;22:1256-1306.

Brignole M, Moya A, de Lange FJ, et al. 2018 European Society of Cardiology Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;00:1-69.

Burns TM, Mauermann ML. The evaluation of polyneuropathies. Neurology. 2011;76:S6-S13.

Callaghan BC, Cheng H, Stables CL, et al. Diabetic neuropathy: clinical manifestations and current treatments. Lancet Neurol. 2012;11(6):521-534.


Carbajal-Ramirez A, Hernandez-Dominguez JA, Molina-Ayala MA, et al. Early identification of peripheral neuropathy based on sudomotor dysfunction in Mexican patients with type 2 diabetes. BMC Neurol. 2019;19(1):109.

Casellini CM, Parson HK, Richardson MS, et al. Sudoscan, a noninvasive tool for detecting diabetic small fiber neuropathy and autonomic dysfunction. Diabetes Technol Ther. 2013;15(11):948-953.

Cheshire WP. Postural tachycardia syndrome. [UpToDate Web site]. 02/14/2023. Available at: https://www.uptodate.com/contents/postural-tachycardia-syndrome?topicRef=5103&source=see_link [via subscription only]. Accessed March 27, 2024.

Cheshire WP, Freeman R, Gibbons CH, et al. Electrodiagnostic assessment of the autonomic nervous system: A consensus statement endorsed by the American Autonomic Society, American Academy of Neurology, and the International Federation of Clinical Neurophysiology. Clin Neurophysiol. 2021;132(2):666-682.

da Silva AKF, Penachini da Costa de Rezende Barbosa M, Marques Vanderlei F, et al. Application of heart rate variability in diagnosis and prognosis of individuals with diabetes mellitus: systematic review. Ann Noninvasive Electrocardiol. 2016;21(3):223-235.


D'Amato C, Greco C, Lombardo G, et al. The diagnostic usefulness of the combined COMPASS 31 questionnaire and electrochemical skin conductance for diabetic cardiovascular autonomic neuropathy and diabetic polyneuropathy. J Peripher Nerv Syst. 2020;25(1):44-53.


Didangelos T, Zografou I, Iliadis F, et al. Validation of Neuropad in the assessment of peripheral diabetic neuropathy in patients with Diabetes Mellitus versus the Michigan Neuropathy Screening Instrument, 10 g Monofilament application and Biothesiometer measurement. Curr Vasc Pharmacol. 2020;18(5):517-522.

Dimachkie MM, Barohn RJ. Guillain-Barre syndrome and variants. Neurol Clin. 2013;31(2):491-510.

Draznin B, Aroda VR, Bakris G, et al. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Suppl 1):S185-S194.

Dyck PJ, Karnes JL, O'Brien PC, et al. The Rochester diabetic neuropathy study: reassessment of tests and criteria for diagnosis severity. Neurology. 1992;42:1164-1170.


ElSayed NA, Aleppo G, Aroda VR, et al. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S203-S215. 

England JD, Gronseth GS, Franklin G, et al. Practice parameter: evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review): report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Neurology. 2009;72:177-184.

Ewing DJ, Martyn CN, Young RJ, et al. The value of cardiovascular autonomic function tests: 10 years experience in diabetes. Diabetes Care.1985;8(5):491-498.

Ewing DJ, Campbell IW, Clarke BF, et al. Assessment of cardiovascular effects in diabetic autonomic neuropathy and prognostic implications. Ann Intern Med.1980;92(2):308-311.


Fortanier E, Delmont E, Verschueren A, et al. Quantitative sudomotor test helps differentiate transthyretin familial amyloid polyneuropathy from chronic inflammatory demyelinating polyneuropathy. Clin Neurophysiol. 2020;131(5):1129-1133.


Franca da Silva AK, Penachini da Costa de Rezende Barbosa M, Marques Vanderlei F, et al. Application of heart rate variability in diagnosis and prognosis of individuals with diabetes mellitus: systematic review. Ann Noninvasive Electrocardiol. 2016;21(3):223-235.

Freeman R. Autonomic peripheral neuropathy. Lancet. 2005;365(9466):1259-1270.

Garcia-Civera R, Ruiz-Granell R, Morell-Cabedo S, et al. Selective use of diagnostic tests in patients with syncope of unknown cause. J Am Coll Cardiol. 2003;41(5):788-790.

Gibbons CH, Cheshire WP, Fife TD. American Academy of Neurology Model Coverage Policy: Autonomic Testing. October 2014. Available at: https://www.aan.com/siteassets/home-page/tools-and-resources/practicing-neurologist--administrators/billing-and-coding/model-coverage-policies/14autonomicmodel_tr.pdf. Accessed March 27, 2024.

Goldberger AL, Stein PK. Evaluation of heart rate variability. [UpToDate Web site]. 08/08/2022. Available at: https://www.uptodate.com/contents/evaluation-of-heart-rate-variability/print?search=autonomic nervous system&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 [via subscription only]. Accessed March 27, 2024.

Goldstein DS, Robertson D, Esler M, et al. Dysautonomias: clinical disorders of the autonomic nervous system. Ann Intern Med. 2002;137(9):753-763.

Grubb BP, Temesy-Armos P, Moore J, et al. Head-upright tilt-table testing in evaluation and management of the malignant vasovagal syndrome. Am J Cardiol. 1992;69:904-908.

Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med. 2007;120:841-847.

Hoeldtke RH, Bryner KD, Horvath GG, et al. Redistribution of sudomotor responses is an early sign of sympathetic dysfunction in type 1 diabetes. Diabetes. 2001;50:436-443.

Hovaguimian A, Gibbons CH. Diagnosis and treatment of pain in small fiber neuropathy. Curr Pain Headache Rep. 2011;15(3):193-200.

Illigens BMW, Gibbons CH. Sweat testing to evaluate autonomic function. Clin Auton Res. 2009;19(2):79-87.

Kamenov ZA, Petrova JJ, Christov VG. Diagnosis of diabetic neuropathy using simple somatic and a new autonomic (neuropad) tests in the clinical practice. Exp Clin Endocrinol Diabetes. 2010;118(4):226-233.

Kenny RA, Ingram A, Bayliss J, et al. Head-up tilt: a useful test for investigating unexplained syncope. Lancet.1986;1(8494):1352-1354.


Kings Technology Evaluation Centre. Neuropad test for the early detection of diabetic foot neuropathy. 2017. Available at: https://www.nice.org.uk/guidance/mtg38/documents/assessment-report. Accessed March 27, 2024.

Klein CM. Evaluation and management of autonomic nervous system disorders. Semin Neurol. 2008;28(2):195-204.


Lai YR, Huang CC, Cheng BC, et al. Feasibility of combining heart rate variability and electrochemical skin conductance as screening and severity evaluation of cardiovascular autonomic neuropathy in type 2 diabetes. J Diabetes Investig. 2021;12(9):1671-1679.


Lin K, Wu Y, Liu S, et al. The application of sudoscan for screening microvascular complications in patients with type 2 diabetes. PeerJ. 2022;10:e13089.

Low PA. Composite autonomic scoring scale for laboratory quantification of generalized autonomic failure. Mayo Clin Proc.1993;68:748-752.

Low PA. Testing the autonomic nervous system. Semin Neurol. 2003;23(4):407-421.

Low PA, Caskey PE, Tuck RR, et al. Quantitiative sudomotor axon reflex test in normal and neuropathic Subjects. Ann Neurol.1983;14:573-580.

Low VA, Sandroni P, Fealey RD, et al. Detection of mall-fiber neuropathy by sudomotor testing. Muscle Nerve. 2006;34(1):57-61.

McDougall AJ, McLeod JG. Autonomic neuropathy, II: Specific peripheral neuropathies. J Neurol Sci. 1996;138(1-2):1-13.

Meena AK, Khadilkar SV, Murthy JMK. Treatment guidelines for Guillain-Barré​ syndrome. Ann Indian Acad Neurol. 2011;14(S1):S73-S81.

Murray A, Ewing DJ, Campbell IW, et al. RR Interval variations in young male diabetics. Br Heart J. 1975;37:882-885.


National Institute for Health and Care Excellence (NICE). Neuropad for detecting preclinical diabetic peripheral neuropathy [MTG38]. 2018. Available at: https://www.nice.org.uk/guidance/mtg38. Accessed March 27, 2024.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35395: Autonomic Function Tests. [Novitas Web site]. Original: 04/07/2016. (Revised: 11/14/2019). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35395&ver=48&Date=03/25/2020&SearchType=Advanced&DocID=l35395&search_id=&service_date=&bc=KAAAAAgAAAAA&. Accessed March 27, 2024.

Novitas Solutions, Inc. Local Coverage Article. A54954: Autonomic Function Tests. [Novitas Web site]. Original: 04/07/2016. (Revised: 01/01/2023). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=54954. Accessed March 27, 2024.


Palma JA, Kaufmann H. Mechanisms, causes, and evaluation of orthostatic hypotension. [UpToDate Web site]. 11/15/2023. Available at: https://www.uptodate.com/contents/mechanisms-causes-and-evaluation-of-orthostatic-hypotension?search=autonomic nervous system&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 [via subscription only]. Accessed March 27, 2024.


Park JY, Yang D, Yang HJ, et al. Quantitative autonomic function test in differentiation of multiple system atrophy from idiopathic Parkinson disease. Chin Med J. 2019;132(16):1919-1924.

Peltier A, Smith AG, Russell JW, et al. Reliability of quantitative sudomotor axon reflex testing and quantitative sensory testing in neuropathy of impaired glucose regulation. Muscle Nerve. 2009;39(4):529-535.


Policy Department, American Association of Neuromuscular & Electrodiagnostic Medicine, Rochester, Minnesota, USA. Proper performance of autonomic function testing. Muscle Nerve. 2017;55(1):3-4.

Ponirakis G, Petropoulos IN, Fadavi H, et al. The diagnostic accuracy of Neuropad for assessing large and small fibre diabetic neuropathy. Diabet Med. 2014;31(12):1673-1680.

Pop-Bosui R. Cardiac autonomic neuropathy in diabetes: a clinical perspective. Diabetes Care. 2010;33(2):434-441.

Pop-Bosui R, Boulton AJM, Feldman EL, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care. 2017;40:136-154.


Popescu C. Small fiber neuropathy in Parkinson's disease explored by the sudoscan. Parkinsonism Relat Disord. 2019;66:261-263.

Quattrini C, Jeziorska M, Tavakoli M, et al. The Neuropad test: a visual indicator test for human diabetic neuropathy. Diabetologia. 2008;51(6):1046-1050.


Rajan S, Campagnolo M, Callaghan B, et al. Sudomotor function testing by electrochemical skin conductance: does it really measure sudomotor function? Clin Auton Res. 2019;29(1):31-39.

Rutkove SB. Overview of polyneuropathy. [UpToDate Web site]. 08/23/2022. Available at: https://www.uptodate.com/contents/overview-of-polyneuropathy?source=history_widget [via subscription only]. Accessed March 27, 2024.

Sagrista-Sauleda J, Romero-Ferrer B, Moya A, et al. Variations in diagnostic yield of head-up tilt test and electrophysiology in groups of patients with syncope of unknown origin. Eur Heart J. 2001;22:857-865.

Spallone V, Bellavere F, Scionti L, et al. Recommendations for the use of cardiovascular tests in diagnosing diabetic autonomic neuropathy. Nutr Metab Cardiovasc Dis. 2011;21:69-78.

Spallone V, Ziegler D, Freeman R, et al. Cardiovascular autonomic neuropathy in diabetes: clinical impact, assessment, diagnosis, and management. Diabetes Metab Res Rev. 2011;27:639-653.

Sra JS, Anderson AJ, Sheikh SH, et al. Unexplained syncope evaluated by electrophysiologic studies and head-up tilt testing. Ann Intern Med. 1991;114:1013-1019.

Stewart JD, Low PA, Fealey RD. Distal small fiber neuropathy: results of tests of sweating and autonomic cardiovascular reflexes. Muscle Nerve.1992;15:661-665.

Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific statement on the evaluation of syncope. J Am Coll Cardiol. 2006;47(2):473-484.

Thaisetthawatkul P, Filho JAM, Herrman DN. Contribution of QSART to the diagnosis of small fiber neuropathy. Muscle Nerve. 2013;48:883-888.

Tobin K, Giuliani MJ, Lacomis D. Comparison of different modalities for detection of small fiber neuropathy. Clinical Neurophysiol.1999;110:1909-1912.

Valensi P, Sachs RN, Harfouche B, et al. Predictive value of cardiac autonomic neuropathy in diabetic patients with or without silent myocardial ischemia. Diabetes Care. 2001;24(2):339-343.


van Bilsen M, Patel HC, Bauersachs J, et al. The autonomic nervous system as a therapeutic target in heart failure: a scientific position statement from the Translational Research Committee of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2017;19(11):1361-1378. 

Vinik AI, Ziegler D. Diabetic cardiovascular autonomic neuropathy. Circulation. 2007;115(3):387-397.


Xu X, Liao J, Dong Q, et al. Clinical utility of SUDOSCAN in predicting autonomic neuropathy in patients with Parkinson's disease. Parkinsonism Relat Disord. 2019;64:60-65.

Zografou I, Iliadis F, Sambanis C, et al. Validation of Neuropad in the assessment of peripheral diabetic neuropathy in patients with diabetes mellitus versus the Michigan neuropathy screening instrument, 10g monofilament application and biothesiometer measurement. Curr Vasc Pharmacol. 2020;18(5):517-522.

Coding

CPT Procedure Code Number(s)
MEDICALLY NECESSARY

95921, 95922, 95923, 95924

THE FOLLOWING CODE IS USED TO REPRESENT SIMULTANEOUS, INDEPENDENT, QUANTITATIVE MEASURES OF BOTH PARASYMPATHETIC FUNCTION AND SYMPATHETIC FUNCTION, BASED ON TIME-FREQUENCY ANALYSIS OF HEART RATE VARIABILITY CONCURRENT WITH TIME-FREQUENCY ANALYSIS OF CONTINUOUS RESPIRATORY ACTIVITY, WITH MEAN HEART RATE AND BLOOD PRESSURE MEASURES, DURING REST, PACED (DEEP) BREATHING, VALSALVA MANEUVERS, AND HEAD-UP POSTURAL CHANGE

95999​

NOT COVERED

THE FOLLOWING CODE IS USED TO REPRESENT AUTONOMIC NERVOUS SYSTEM TESTING WITH DEVICES (eg: SUDOSCAN, ESC, and ANSAR ANX 3.0)

95999

ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)

MEDICALLY NECESSARY​

A52.15 Late syphilitic neuropathy
E08.40Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
E08.41Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.42Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.43Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E08.44Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.49Diabetes mellitus due to underlying condition with other diabetic neurological complication
E08.610Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy
E09.40Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified
E09.41Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy
E09.42Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
E09.43Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy
E09.44Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy
E09.49Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication
E09.610Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy
E10.40Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44Type 1 diabetes mellitus with diabetic amyotrophy
E10.49Type 1 diabetes mellitus with other diabetic neurological complication
E10.610Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E11.40Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.610Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.41 Other specified diabetes mellitus with diabetic mononeuropathy
E13.42 Other specified diabetes mellitus with diabetic polyneuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.44 Other specified diabetes mellitus with diabetic amyotrophy
E13.49 Other specified diabetes mellitus with other diabetic neurological complication
E13.610Other specified diabetes mellitus with diabetic neuropathic arthropathy
E85.0 Non-neuropathic heredofamilial amyloidosis
E85.1 Neuropathic heredofamilial amyloidosis
E85.3 Secondary systemic amyloidosis
E85.4 Organ-limited amyloidosis
E85.81 Light chain (AL) amyloidosis
E85.82 Wild-type transthyretin-related (ATTR) amyloidosis
E85.89 Other amyloidosis
G12.23 Primary lateral sclerosis 
G12.24 Familial motor neuron disease
G12.25 Progressive spinal muscle atrophy
G13.0 Paraneoplastic neuromyopathy and neuropathy 
G13.1 Other systemic atrophy primarily affecting central nervous system in neoplastic disease
G23.0 Hallervorden-Spatz disease
G23.1 Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski]
G23.2 Striatonigral degeneration
G23.8 Other specified degenerative diseases of basal ganglia
G23.9 Degenerative disease of basal ganglia, unspecified
G56.83Other specified mononeuropathies of bilateral upper limbs
G56.93Unspecified mononeuropathy of bilateral upper limbs
G57.83Other specified mononeuropathies of bilateral lower limbs
G57.93Unspecified mononeuropathy of bilateral lower limbs
G58.0 Intercostal neuropathy
G60.2 Neuropathy in association with hereditary ataxia
G60.3 Idiopathic progressive neuropathy
G60.8 Other hereditary and idiopathic neuropathies
G60.9 Hereditary and idiopathic neuropathy, unspecified​
G61.1 Serum neuropathy 
G61.82 Multifocal motor neuropathy
G62.9 Polyneuropathy, unspecified
G90.01Carotid sinus syncope
G90.09 Other idiopathic peripheral autonomic neuropathy
G90.3 Multi-system degeneration of the autonomic nervous system
G90.4 Autonomic dysreflexia
G90.50 Complex regional pain syndrome I, unspecified
G90.511Complex regional pain syndrome I of right upper limb
G90.512Complex regional pain syndrome I of left upper limb
G90.513Complex regional pain syndrome I of upper limb, bilateral
G90.519Complex regional pain syndrome I of unspecified upper limb
G90.521Complex regional pain syndrome I of right lower limb
G90.522Complex regional pain syndrome I of left lower limb
G90.523Complex regional pain syndrome I of lower limb, bilateral
G90.529Complex regional pain syndrome I of unspecified lower limb
G90.59 Complex regional pain syndrome I of other specified site
G90.81Serotonin syndrome
G90.89Other disorders of autonomic nervous system
G90.9 Disorder of the autonomic nervous system, unspecified
​G90.A​Postural orthostatic tachycardia syndrome [POTS]
G99.0 Autonomic neuropathy in diseases classified elsewhere
I95.0 Idiopathic hypotension
I95.1 Orthostatic hypotension
I95.89 Other hypotension
I95.9 Hypotension, unspecified
L74.510Primary focal hyperhidrosis, axilla
L74.511Primary focal hyperhidrosis, face
L74.512Primary focal hyperhidrosis, palms
L74.513Primary focal hyperhidrosis, soles
L74.519Primary focal hyperhidrosis, unspecified
L74.52 Secondary focal hyperhidrosis
R00.0 Tachycardia, unspecified
R55   Syncope and collapse
R61   G​eneralized hyperhidrosis​​

HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

10/1/2024
10/1/2024
10/1/2024
07.03.23
Medical Policy Bulletin
Commercial
No
Connect with Us

2024 Independence Blue Cross

Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.