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DESCRIPTIONThe autonomic nervous system (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 has two major divisions: the sympathetic and parasympathetic systems. Many organs are controlled primarily by either the sympathetic or parasympathetic system, although they may receive input from both; occasionally, functions are reciprocal (e.g., sympathetic input increases heart rate; parasympathetic decreases it).
The sympathetic nervous system is catabolic and activates fight-or-flight responses. Thus, sympathetic output increases heart rate and contractility, bronchodilation, hepatic glycogenolysis and glucose release, BMR (basal metabolism rate), and muscular strength; it also causes sweaty palms. Less immediately-life-preserving functions (e.g., digestion, renal filtration) are decreased.
The parasympathetic nervous system is anabolic; it conserves and restores. Gastrointestinal secretions and motility (including evacuation) are stimulated, heart rate is slowed, and blood pressure decreases.
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 a patient has symptoms suggesting autonomic dysfunction, cardiovagal, adrenergic, and sudomotor tests are usually done to help determine severity and distribution of the dysfunction.
Cardiovagal innervation testing evaluates heart rate response to deep breathing and to the Valsalva maneuver, via electrocardiogram rhythm strip. If the ANS is intact, heart rate varies with these maneuvers; the ratio of longest to shortest R-R interval (Valsalva ratio) should be 1.4 or greater.
Vasomotor adrenergic innervation testing evaluates response of beat-to-beat blood pressure to the head-up tilt and Valsalva maneuver. The head-up tilt shifts blood to dependent parts, causing reflex responses. The Valsalva maneuver increases intrathoracic pressure and reduces venous return, causing blood pressure changes and reflex vasoconstriction. In both tests, the pattern of responses is an index of adrenergic function.
The quantitative sudomotor axon reflex test (QSART) evaluates integrity of postganglionic neurons using iontophoresis; electrodes filled with acetylcholine are placed on the legs and wrist to stimulate sweat glands, and the volume of sweat is then measured. The test can detect decreased, absent, or persistent (after stimulus discontinuation) sweat production. The silastic sweat imprint differs from QSART in that the recording is an imprint of the sweat droplets appearing as indentations on silastic material.
The thermoregulatory sweat test (TST) evaluates both preganglionic and postganglionic pathways. After a dye is applied to the skin, patients enter a closed compartment that is heated to cause sweating. Sweating causes the dye to change color, so that areas of anhidrosis and hypohidrosis are apparent and can be calculated as a percentage of body surface area.
Sympathetic skin response (SSR) provides an index of sweat production by measuring change in skin resistance following random electrical stimulation over the palms and soles.
Quantitative direct and indirect axon reflex testing (QDIRT) is defined by Illigens and Gibbons as a novel new technique to evaluate the postganglionic sympathetic cholinergic sudomotor function by measuring the direct and axon-reflex mediated sweat response in a dynamic fashion. Sweat glands are stimulated by acetylcholine iontophoresis and sweat is displayed via an activator dye followed by digital photographs over time.
A variety of monitoring and testing equipment can be used for ANS testing; one example is the ANX 3.0™. In 1994, the Ansar Group, Inc. received U.S. Food and drug Administration (FDA) 510(K) clearance for their new autonomic nervous system monitoring technology; in 2004 Ansar introduced the ANX 3.0, which is their latest generation non-invasive, real-time, digital monitor of autonomic nervous system functioning. The ANX 3.0 monitors both branches of the ANS simultaneously.
POLICYAutonomic nervous system (ANS) testing, including parasympathetic function (cardiovagal innervation), sympathetic adrenergic function (vasomotor adrenergic innervation), and sudomotor function (quantitative sudomotor axon reflex test [QSART], thermoregulatory sweat test [TST], and silastic sweat imprint test), may be considered medically necessary for use as a diagnostic tool to evaluate symptoms of vasomotor instability after more common causes have been excluded by other testing, for any of the following:
1. Diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive autonomic neuropathy, including:
2. Evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy;
3. Differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of consciousness;
4. Evaluate inadequate response to beta blockade in vasodepressor syncope;
5. Evaluate distressing symptoms in the patient with a clinical picture suspicious for distal small fiber neuropathy in order to diagnose the condition;
6. Differentiate the cause of postural tachycardia syndrome;
7. Evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure;
8. Evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical exam;
9. Diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient;
10. Evaluate and diagnose sympathetically maintained pain, as in reflex sympathetic dystrophy or causalgia; or
11. Evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic failure.
Autonomic nervous system (ANS) testing is considered investigational for all other indications that do not meet the above criteria, including but not limited to:
1. Screening or routine testing of patients without signs or symptoms of autonomic dysfunction, including patients with diabetes, hepatic or renal disease;
2. Testing for the sole purpose of monitoring disease intensity or treatment efficacy in diabetes, hepatic or renal disease;
3. Patients with a clearly diagnosed somatic neuropathy, especially demyelinating neuropathies;
4. Patients with uncomplicated vasovagal syncope;
5. General diagnosis of conditions including, but not limited to:
Sympathetic skin response (SSR) testing is considered investigational.
Quantitative direct and indirect axon reflex testing (QDIRT) is considered investigational.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
05/01/2013: New policy added. Approved by Medical Policy Advisory Committee.
02/27/2015: Policy reviewed. Policy statement updated to add chronic fatigue syndrome, fibromyalgia, allergic conditions, and hypertension as investigational conditions. Sources section updated.
08/21/2015: Code Reference section updated for ICD-10.
06/06/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
Blue Cross Blue Shield of Texas medical policy, Autonomic Nervous System (ANS) Testing
Blue Cross Blue Shield Association policy # 2.01.96
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.