Anthem Blue Cross Connecticut MED.00112 Autonomic Testing Form

This document addresses the use of autonomic testing. This document does not address the use of tilt-table testing.

Note: Please see the following related document for additional information:

• CG-LAB-13 Skin Nerve Fiber Density Testing

Position Statement

Investigational and Not Medically Necessary:

The use of autonomic nervous system function testing for sudomotor function using quantitative sudomotor axon reflex test (QSART), the thermoregulatory sweat test (TST), silastic sweat imprint, sympathetic skin response (SSR), quantitative direct and indirect reflex test of sudomotor function (QDIRT), or SudoScan are considered investigational and not medically necessary for all indications.

The use of autonomic nervous system function testing for cardiovagal innervations is considered investigational and not medically necessary for all indications.

The use of autonomic nervous system function testing for vasomotor adrenergic innervations is considered investigational and not medically necessary for all indications.