Humana Commercial Clinical Policy

Humana Autonomic Nerve Function Testing Form

Effective Date

02/02/2023

Last Reviewed

NA

Original Document

  Reference



Description

The autonomic nervous system (ANS), a branch of the peripheral nervous system, is subdivided into the sympathetic and parasympathetic nervous systems. It is responsible for involuntary functions, including the rate and force of myocardial (heart muscle) contractions; dilation and constriction of the blood vessels and pupils; motility of the gastrointestinal tract; secretion of the sweat glands; and certain functions of the bladder, genital organs, kidneys and lungs.

Autonomic dysfunction may include many different types of diseases affecting any location along the autonomic nervous system pathway with symptoms including, but not limited to, abnormal bladder function, excessive sweating, heart palpitations and persistent dizziness when standing.

Autonomic Nerve Function Testing

Effective Date: 02/02/2023
Revision Date: 02/02/2023
Review Date: 02/02/2023

Policy Number: HUM-0557-008

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Testing for autonomic dysfunction may occur in a collection of tests or measures due to the fact that the ANS extends to nearly every organ system; however, the focus of this medical coverage policy will be on cardiovagal, sudomotor and vasomotor adrenergic testing.

Cardiovagal autonomic testing assesses parasympathetic function (cardiovagal innervation) by measuring the heart rate variability response, via electrocardiogram (ECG), to deep breathing, the Valsalva maneuver and standing. A decrease in heart rate variability indicates a parasympathetic dysfunction.1

Sudomotor testing measures the sympathetic cholinergic component of the ANS responsible for sweat gland function and the production of thermoregulatory sweating.1 Autonomic sudomotor function tests include, but may not be limited to, the following:

  • Quantitative direct and indirect reflex test (QDIRT) (Refer to Coverage Limitations section)
  • Quantitative pilomotor axon reflex test (QPART) (Refer to Coverage Limitations section)
  • Quantitative sudomotor axon reflex test (QSART)
  • Silastic sweat imprint (SSI) (Refer to Coverage Limitations section)
  • Sympathetic skin response (SSR)
  • Thermoregulatory sweat test (TST)

Vasomotor adrenergic autonomic testing is the primary method for evaluating an individual with syncope, orthostatic hypotension, postural tachycardia syndrome and postural dizziness by evaluating sympathetic adrenergic function.1

Ambulatory autonomic nervous system monitors are portable devices that observe and record physiologic parameters such as activity, heart rate, posture and respiration. The device is secured to the individual using a chest and shoulder strap.

Bluetooth technology transfers the real time data to a computer for monitoring. Reported use for ANS monitors includes exercise physiology, psychological studies or public health. Examples of ambulatory ANS monitors include, but may not be limited to, the BioHarness and Zephyr. The BioHarness and Zephyr devices are available over-the-counter without a prescription.

(Refer to Coverage Limitations section) Automated autonomic testing devices use software to simultaneously and independently provide time frequency analysis of both parasympathetic and sympathetic nervous function to regulate blood pressure, heart rate and continuous respiratory activity in response to deep breathing, head up postural changes, rest and the Valsalva maneuver by way of an electronic blood pressure monitor. Purportedly, these devices do not measure expiratory pressure as well as beat to beat blood pressure measurements which fail to provide information about the heart rate stimulus.1 Testing may be performed by automated autonomic testing devices as well. Purportedly, sudomotor testing is performed with individual electrodes or electrode plates. Test results may be revealed as a risk score instead of individual test results. Examples of automated testing devices or software include, but may not limited to, ANS software and SudoPath systems, Critical Care Assessment HRV, ES Complex Software, TM Flow System, and VitalScan systems.

(Refer to Coverage Limitations section) SudoScan purportedly measures electrochemical skin conductance of hands and feet through reverse iontophoresis. For the individual, the test involves standing on sensor plates for the feet and placing the hands on hand sensor plates. These plates act as electrodes. Low voltage is used to activate the sweat glands and measure the chloride ions that flow from the sweat glands in response to the voltage. High conductance (the degree which an object conducts electricity) correlates with normal sweat function and healthy nerve innervation (small C-fibers). Low conductance may represent peripheral or autonomic neuropathy.

(Refer to Coverage Limitations section)For information regarding tilt table testing, please refer to Tilt Table Testing Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for cardiovagal, sudomotor (QSART, SSR, TST) and vasomotor adrenergic autonomic testing for the following indications:

  • Distal small fiber neuropathy; OR
  • Postural orthostatic tachycardia syndrome (POTS); OR
  • Progressive autonomic neuropathies including, but not limited to, any of the following:
    • Amyloid neuropathy; OR
    • Diabetic neuropathy; OR
    • Idiopathic neuropathy; OR
    • Multiple system atrophy; OR
    • Pure autonomic failure; OR
    • Sjogren’s neuropathy; OR
  • Recurrent, unexplained syncope with documentation of inconclusive initial complete history and physical exam and electrocardiogram (ECG); OR
  • Reflex sympathetic dystrophy or complex regional pain syndrome (CRPS) (e.g., sympathetically maintained pain, causalgia)

Coverage Limitations

Humana members may NOT be eligible under the Plan for cardiovagal, sudomotor (QSART, SSR, TST) and vasomotor adrenergic autonomic testing for any indications other than those listed above including, but may not be limited to:

  • Anxiety disorder; OR
  • Chronic fatigue syndrome; OR
  • Flushing syndromes; OR
  • Hyperhidrosis, generalized (secondary) or palmoplantar; OR
  • Irritable bowel syndrome; OR
  • Myofascial pain syndrome/fibromyalgia; OR
  • Predicting foot ulcers; OR
  • Raynaud’s phenomenon; OR

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Somatic symptom disorderThese are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for cardiovagal, sudomotor (QSART, SSR, TST) and vasomotor adrenergic autonomic testing for general population screening.This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for any autonomic nerve function testing method other than those listed above including, but may not be limited to:

  • Automated autonomic testing devices (eg, VitalScan); OR
  • QDIRT test; OR
  • QPART test; OR
  • SSI test; OR
  • Sudoscan

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for ambulatory autonomic nervous system monitors (eg, BioHarness, Zephyr) for any indication. Although they may be prescribed by a health care practitioner, ambulatory autonomic nervous system monitors (eg, BioHarness, Zephyr) are also available without a prescription and may be obtained over-the-counter (OTC) and are therefore generally excluded in the certificate. In the absence of a certificate exclusion for OTC items ambulatory autonomic nervous system monitors (eg, BioHarness, Zephyr) are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Additional information about autonomic dysfunction may be found from the following websites:

Background

  • American Diabetes Association
  • National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

CPT® Code(s)

  • 95921 - Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio
  • 95922 - Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt
  • 95923 - Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential
    Not Covered if used to report any test outlined in Coverage Limitations section

Autonomic Nerve Function Testing Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0557-008 Page: 7 of 10
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional CPT® Code

  • 95924 - Testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing at least 5 minutes of passive tilt
  • 95999 - Unlisted neurological or neuromuscular diagnostic procedure
    Not Covered if used to report any test outlined in Coverage Limitations section

CPT® Category III Code(s)

No code(s) identified

E1399 - Durable medical equipment, miscellaneous

Not Covered if used to report any device outlined in Coverage Limitations section

References

  1. American Academy of Neurology (AAN). Model Coverage Policy. Autonomic testing. https://www.aan.com. Published October 2014. Accessed December 28, 2022.
  2. American Academy of Neurology (AAN). Practice parameter: evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy and skin biopsy (an evidenced-based review). https://www.aan.com. Published December 3, 2008. Updated January 26, 2019. Accessed December 28, 2022.
  3. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Position Statement. Proper performance of autonomic function testing. https://www.aanem.org. Published August 2016. Updated December 2021. Accessed December 28, 2022.
  4. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Position Statement. Recommended policy for electrodiagnostic medicine. https://www.aanem.org. Published September 1997. Updated November 2019. Accessed December 28, 2022.
  5. American Diabetes Association (ADA). Standards of Care in Diabetes. Retinopathy, neuropathy and foot care. https://www.diabetes.org. Published January 2023. Accessed December 28, 2022.
  6. American Heart Association (AHA). 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope.
  1. https://www.heart.org. Published March 9, 2017. Accessed December 28, 2022.
  2. ClinicalKey. Bradfield JS, Shivkumar K. Cardiovascular manifestations of autonomic disorders. In: Libby P, Bonow RO, Mann D et al. Braunwald’s Heart Disease; A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022:1893- 1902. https://www.clinicalkey.com. Accessed December 22, 2022.
  3. ClinicalKey. Cheshire WP. Autonomic disorders and their management. In: Goldman L, Schafer A. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:2482- 2485.e3. https://www.clinicalkey.com. Accessed December 22, 2022.
  4. ClinicalKey. Grubb BP, Karabin B. Postural orthostatic tachycardia syndrome. In: Zipes PP, Jalife J. Cardiac Electrophysiology: From Cell to Bedside. 8th ed. Elsevier; 2022:1203-1208. https://www.clinicalkey.com. Accessed December 22, 2022.
  5. Hayes, Inc. Medical Technology Directory (ARCHIVED). Autonomic nervous system monitoring for neuropathy. https://evidence.hayesinc.com. Published January 29, 2010. Updated February 4, 2014. Accessed December 13, 2022.
  6. Heart Rhythm Society (HRS). 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. https://www.hrsonline.org. Published May 13, 2015. Updated November 18, 2020. Accessed December 28, 2022.

Autonomic Nerve Function Testing Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0557-008 Page: 9 of 10
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. Merck Manual: Professional Version. Overview of the autonomic nervous system. https://www.merckmanuals.com. Updated September 2021. Accessed December 23, 2022.
  2. Siepmann T, Gibbons CH, Illigens BM, Lafo JA, Brown CM, Freeman R. Quantitative pilomotor axon reflex test. ArchNeurol. 2012;69(11):1488-1492. https://www.jamanetwork.com. Accessed December 29, 2022.
  3. UpToDate, Inc. Approach to flushing in adults. https://www.uptodate.com. Updated November 2022. Accessed December 21, 2022.
  4. UpToDate, Inc. Approach to the differential diagnosis of leg ulcers. https://www.uptodate.com. Updated November 2022. Accessed December 21, 2022.
  5. UpToDate, Inc. Clinical features and diagnosis of myalgic encephalomyelitis/ chronic fatigue syndrome. https://www.uptodate.com. Updated November 2022. Accessed December 21, 2022.
  6. UpToDate, Inc. Clinical manifestations and diagnosis of fibromyalgia in adults. https://www.uptodate.com. Updated November 2022. Accessed January 3, 2023.
  7. UpToDate, Inc. Clinical manifestations and diagnosis of irritable bowel syndrome in adults. https://www.uptodate.com. Updated November 2022. Accessed December 21, 2022.
  8. UpToDate, Inc. Clinical manifestations and diagnosis of the Raynaud phenomenon. https://www.uptodate.com. Updated November 2022. Accessed December 21, 2022.
  9. UpToDate, Inc. Complex regional pain syndrome in adults: pathogenesis, clinical manifestations and diagnosis. https://www.uptodate.com. Updated November 2022. Accessed December 13, 2022.
  10. UpToDate, Inc. Diabetic autonomic neuropathy. https://www.uptodate.com. Updated November 2022. Accessed December 13, 2022.
  11. UpToDate, Inc. Diagnosis and differential diagnosis of Parkinson disease. https://www.uptodate.com. Updated November 15, 2022.

Autonomic Nerve Function Testing Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0557-008 Page: 10 of 10
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. UpToDate, Inc. Generalized anxiety disorder in adults: epidemiology, pathogenesis, clinical manifestations, course, assessment and diagnosis. https://www.uptodate.com. Updated November 2022. Accessed December 21, 2022.
  2. UpToDate, Inc. Mechanism, causes and evaluation of orthostatic hypotension. https://www.uptodate.com. Updated November 2022. Accessed December 13, 2022.
  3. UpToDate, Inc. Overview of polyneuropathy. https://www.uptodate.com. Updated November 2022. Accessed December 13, 2022.
  4. UpToDate, Inc. Postural tachycardia syndrome. https://www.uptodate.com. Updated December 6, 2022. Accessed December 13, 2022.
  5. UpToDate, Inc. Primary focal hyperhidrosis. https://www.uptodate.com. Updated November 2022. Accessed December 21, 2022.
  6. US Food & Drug Administration (FDA). 510(k) summary: SudoC. https://www.fda.gov. Published September 24, 2015. Accessed December 29, 2022.