Autonomic nervous system (ANS) testing evaluates the physiologic responses to various stimuli and assesses the degree of dysfunction of the autonomic nervous system. Autonomic dysfunction is also called autonomic neuropathy or dysautonomia. Dysfunction of the autonomic nervous system can present as a primary disorder or be the result of other diseases such as Parkinson’s disease, diabetes or related to drugs and/or alcohol abuse. Autonomic dysfunction can range from mild to life-threatening. Sometimes the conditions that cause problems are temporary and reversible, other times chronic and may worsen over time. Testing can aid in localization of the dysfunction, narrowing of the differential diagnosis, and in some cases making a clear diagnosis.
The ANS includes the sympathetic autonomic nervous system (SANS) and the parasympathetic autonomic nervous system (PANS). The ANS controls several basic functions, including: heart rate, body temperature, breathing rate, digestion, and sensation. Most organs have nerves from both the sympathetic and parasympathetic systems.
Although there is not a standard battery of tests for ANS testing, testing generally consists of individual tests in three areas; cardiovagal function, vasomotor adrenergic function (the primary method for evaluating patients with syncope, orthostatic hypotension, postural tachycardia syndrome, and postural dizziness) and sudomotor function or sweat testing.
According to the American Academy of Neurology (AAN) standard techniques used in autonomic testing include:
Measuring heart rate and blood pressure variability during deep breathing, tilt table, five minutes of standing and the Valsalva maneuver (attempting to breathe out with nose and mouth blocked) to assess cardiovagal and vasomotor function (e.g., ANX 3.0® ANS)
Thermoregulatory sweat test (TST)
Sympathetic skin response (SSR)
Quantitative Sudomotor Axon Reflex Test (QSART device)
Autonomic testing by well-established methods performed under controlled conditions, can take 90-120 minutes, and requires interpretation by a physician familiar with autonomic nervous system physiology. Automated testing devices (e.g. QHRV System or VitalScan® ANS, ANSAR®, ZYTO® ScanHand Cradle, Neuropad®, Sudoscan®, EZScan®) and newer methodologies [e.g., quantitative direct and indirect testing of sudomotor function (QDIRT)] have been proposed that generate data after approximately 10-15 minutes of testing and without physician interpretation. According to the AAN these methods and/or devices have insufficient published literature to establish clinical utility.
Autonomic nervous system testing, consisting of a battery of tests in several domains, is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Autonomic nervous system testing is considered investigational for all other conditions/diseases, including, but not limited, to the evaluation of the following conditions:
Chronic fatigue syndrome
Myofascial pain syndrome/fibromyalgia
Anxiety and other psychological disorders
Irritable bowel syndrome
Screening of asymptomatic individuals
Monitoring progression of disease or response to treatment
Autonomic nervous system testing using automated devices (e.g. VitalScan® ANS, ANSAR®, ZYTO® Scan Hand Cradle, Neuropad®, Sudoscan®, EZScan®), in which software generates an interpretation, is considered investigational for all indications.
Autonomic nervous system testing is considered medically appropriate if ALL of the following criteria are met:
Signs and/or symptoms of autonomic dysfunction such as ONE or MORE of the following:
Recurrent unexplained syncope
Recurrent orthostatic dizziness
Central neurodegenerative disorders (e.g., Parkinson’s disease, Lewy body disease)
Peripheral neuropathy (e.g., amyloidosis, Fabry’s disease, Sjögren’s syndrome, autoimmune and idiopathic neuropathies)
Progressive autonomic neuropathy
Postural tachycardia syndrome.
Multiple systems atrophy
Familial dysautonomia or Riley Day syndrome
Hereditary sensory and autonomic neuropathies
Lambert Eaton myasthenic syndrome
A definitive diagnosis cannot be made from clinical examination and routine laboratory testing alone
Diagnosis of the suspected autonomic disorder may lead to a change in management or eliminate the need for further testing
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ANS testing should be performed in the setting of a dedicated ANS testing laboratory, under closely controlled conditions and interpretation of results performed by an individual with expertise in ANS testing. Portable, automated testing that is intended for office use has not been validated by clinical studies and has a greater potential to lead to erroneous results.
American Academy of Neurology. (2009, Reaffirmed 2016). Practice parameter: Evaluation of distal symmetric polyneuropathy: Role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Retrieved December 28, 2017 from http://www.neurology.org.
American Academy of Neurology. (2014, September). Autonomic testing - model coverage policy. Retrieved February 18, 2015 from www.aan.com.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2017, May). Proper performance of autonomic function testing. Retrieved December 28, 2017 from www.aanem.com.
American Diabetes Association (2018) Standards of medical care in diabetes - 2018. Retrieved September 11, 2019 from www.diabetes.org/diabetescare.
BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2018). Autonomic nervous system testing (2.01.96). Retrieved September 10, 2018 from BlueWeb. (18 articles and/or guidelines reviewed)
Casellini, C., Parson, H., Richardson, M., Nevoret, M., and Vinik, A. (2013) Sudoscan®, a noninvasive tool for detecting diabetic small fiber neuropathy and autonomic dysfunction. Diabetes Technology & Therapeutics, 15 (11), 948-953. (Level 3 evidence - industry sponsored)
Chelimsky, G., Ialacci, S., and Chelimsky, T. (2013). Autonomic testing in healthy subjects - preliminary observations. Clinical Autonomic Research. 23 (2): 113-116. (Level 3 evidence)
Coon, E., Sletten, D., Suarez, M., Mandrekar, J., Ahlskog, J., et al. (2015). Clinical features and autonomic testing predict survival in multiple system atrophy. Brain, 138, 3623-3631. (Level 4 evidence)
Iodice, V., and Sandroni, P. (2014). Autonomic neuropathies. Continuum, 20 (5), 1373-1397. (Level 3 evidence)
Tannus, L., Sperandei, S., Montenegro Júnior, R., Carvalho, V., Pedrosa, H., Felix, M.,et. al. (2013). Reproducibility of methods used for the assessment of autonomous nervous system's function. Autonomic Neuroscience: Basic and Clinical. 177 (2013) 275-279. (Level 2 evidence)
Van Cauwenbergh, D., Nijs, J., Kos, D., Van Weijnen, L., Struyf, F., & Meeus, M. (2014). Malfunctioning of the autonomic nervous system in patients with chronic fatigue syndrome: a systematic literature review. European Journal of Clinical Investigation, 44 (5), 516-526. Abstract retrieved February 22, 2017 from PubMed database.
ORIGINAL EFFECTIVE DATE: 7/11/2015
MOST RECENT REVIEW DATE: 1/31/2019
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