Autonomic Nervous System Testing
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Defines medical necessity, limitations, and coding guidance for autonomic nervous system testing for Network Health commercial lines and references Medicare determinations for Medicare Advantage members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Autonomic Nervous System Testing
Medically necessary indications
Autonomic testing (cardiovagal, sudomotor, vasomotor adrenergic) is considered medically necessary when ANY one of the following indications is met:
Covered indications
- 1) Distal small fiber neuropathy; OR
- 2) Postural orthostatic tachycardia syndrome; OR
ALL of the following
- Progressive autonomic neuropathies - examples: a. Amyloid neuropathy; OR b. Diabetic neuropathy; OR c. Idiopathic neuropathy; OR d. Multiple system atrophy; OR e. Pure autonomic failure; OR f. Sjogren's neuropathy
- 4) Recurrent unexplained syncope with documentation of inconclusive initial complete history and physical exam and electrocardiogram (ECG); OR
- 5) Reflex sympathetic dystrophy or complex regional pain syndrome (CRPS) (for example, sympathetically maintained pain, causalgia); OR
- 6) To evaluate change in type, distribution or severity of autonomic deficits in members with autonomic failure; OR
- 7) To evaluate response to treatment in members with autonomic failure who demonstrate a change in clinical exam
This policy considers autonomic testing medically necessary only for defined clinical indications. Tests performed for presentations such as anxiety, chronic fatigue syndrome/myalgic encephalomyelitis, flushing syndromes, generalized or palmoplantar hyperhidrosis, irritable bowel syndrome, myofascial pain syndrome/fibromyalgia, concussion, somatic symptom disorder, Raynaud phenomenon, traumatic brachial plexus injury, traumatic brain injury, and testing to predict foot ulcers are considered experimental and investigational and are not covered.
Use of portable, automated autonomic nerve testing devices (examples listed in the source include TM-FLOW/EZSCAN, Sudoscan, QDIRT/QPART, and ambulatory autonomic monitors) is considered experimental and investigational and is not supported by this policy.
Routine screening of asymptomatic members — including those with diabetes, hepatic disease, or renal disease — is not medically necessary and therefore not covered under this policy.
Consistent with the statement above, autonomic testing performed for the purpose of screening members who have no signs or symptoms of autonomic dysfunction is not considered medically necessary and may be denied.
Coding
| 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. |
Provider Actions and Documentation Requirements
Verify eligibility and follow CMS determinations for MA members
Follow the member's specific Certificate of Coverage / Evidence of Coverage for eligibility and any prior authorization requirements; for Medicare Advantage members, follow applicable CMS National and Local Coverage Determinations (NCD/LCD).
Step therapy not specified
Step therapy requirements are not specified in this policy.
Provide required clinical documentation
Document a complete history and physical exam and include an ECG when relevant (for example, recurrent unexplained syncope with an inconclusive initial evaluation); also document the specific covered indication that supports testing.
- Complete history and physical exam
- Electrocardiogram (ECG) when relevant (e.g., recurrent unexplained syncope with inconclusive initial evaluation)
- Clear documentation of the specific covered indication from the policy
Do not order testing for asymptomatic screening
Screening asymptomatic members (including those with diabetes, hepatic or renal disease) is not considered medically necessary and may be denied; do not submit autonomic testing for members without signs or symptoms of autonomic dysfunction.
Avoid portable automated autonomic devices — potential denials
Autonomic nerve testing using portable, automated devices (for example TM-FLOW/EZSCAN, Sudoscan, QDIRT/QPART, ambulatory autonomic monitors) is considered experimental/investigational and may be denied.
- Examples listed in policy: TM-FLOW (EZSCAN), Sudoscan, QDIRT/QPART, ambulatory autonomic nervous system monitors
Background
Autonomic testing evaluates three principal domains: parasympathetic cardiovagal function (assessed by heart rate variability measures such as deep breathing, Valsalva ratio, and heart rate response to standing), sympathetic adrenergic (vasomotor) function (assessed by beat-to-beat blood pressure and heart rate changes, often including passive tilt testing), and sudomotor function (assessed with tests such as QSART, thermoregulatory sweat testing, silastic sweat imprint, or sympathetic skin response). These complementary domains are used together to diagnose disorders such as small fiber neuropathy, postural orthostatic tachycardia syndrome (POTS), syncope/orthostatic hypotension, complex regional pain syndromes, and progressive autonomic neuropathies, and to evaluate changes in distribution or severity of autonomic deficits or response to treatment when clinically indicated.
Definitions
Revision History
Policy reviewed and approved (annual review); grammatical and formatting changes and updated references; effective/review date set to 2025-08-21.
Annual review with grammatical and formatting changes and updated references.
Yearly review with grammatical and formatting changes; approved by Medical Policy Committee.
Yearly review with grammatical and formatting changes and removal of one retired reference; approved by Medical Policy Committee.
Policy originated (new policy).
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