The autonomic nervous system (ANS) controls physiologic processes that are not under conscious control. ANS disorders, also called dysautonomias, are heterogeneous in etiology, clinical symptoms, and severity. These disorders can be limited and focal, such as individuals with isolated neurocardiogenic syncope or idiopathic palmar hyper hidrosis. At the other extreme, some ANS disorders can be widespread and severely disabling, such as multiple systems atrophy, which leads to widespread and severe autonomic failure.
ANS testing consists of a battery of tests intended to evaluate the integrity and function of the ANS. 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. Autonomic testing by well-established methods performed under controlled conditions, can take 90-120 minutes. The results of the battery of tests requires interpretation by a physician familiar with autonomic nervous system physiology.
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
Thermoregulatory sweat test (TST)
Sympathetic skin response (SSR)
Quantitative Sudomotor Axon Reflex Test (QSART device)
Numerous automated ANS testing devices have been cleared for marketing by the U.S. Food and Drug Administration through the 510k process (e.g., QHRV System, VitalScan®, ANSAR® ANX, ZYTO® Scan Hand Cradle, Neuropad®, Sudoscan®, EZScan®, Natus VikingQuest, Bodytronic® 200). These devices, along with newer methodologies (e.g., quantitative direct and indirect testing of sudomotor function [QDIRT]) propose to generate data after approximately 10-15 minutes of testing and without physician interpretation. According to the American Academy of Neurology, these methods and/or devices have insufficient published literature to establish clinical utility. These automated devices perform a simplified battery of autonomic tests, typically the heart rate response to deep breathing, the heart rate response to a Valsalva maneuver, and the blood pressure response to standing. Many devices are severely limited in the validity of the data they generate because they do not measure or control for expiratory pressure or include beat-to-beat blood pressure measurement, both of which are requirements, not only for scientifically accurate assessment, but also for billing of autonomic testing.
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., QHRV System, VitalScan®, ANSAR® ANX, ZYTO® Hand Cradle, Neuropad®, Sudoscan®, EZScan®, Natus VikingQuest, Bodytronic® 200), 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
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
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. Automated testing in which software generates an interpretation 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.
BlueCross BlueShield Association. Evidence Positioning System. (7:2019). Autonomic nervous system testing (2.01.96). Retrieved June 16, 2020 from https://www.evidencepositioningsytem.com/. (18 articles and/or guidelines reviewed)
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)
Yousif, D., Bellos, I., Penzlin, A., Hijazi, M.M., Illigens, B.M., Pinter, A., & Siepmann, T. (2019). Autonomic dysfunction in preeclampsia: a systematic review. Frontiers in Neurology, 10, 816. Abstract retrieved August 28, 2019 from PubMed database.
Ziemssen, T & Siepmann, T. (2019). The investigation of the cardiovascular and sudomotor autonomic nervous system - a review. Frontiers in Neurology, 10, 53. (Level 2 evidence)
ORIGINAL EFFECTIVE DATE: 7/11/2015
MOST RECENT REVIEW DATE: 8/13/2020
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