Autonomic Testing
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Defines medical necessity, coverage stance, exclusions, and coding guidance for autonomic nervous system testing for Geisinger Health Plan members across commercial, Medicare, CHIP, and Medicaid lines of business.
Coverage Criteria for Autonomic Testing
Medically necessary indications
Autonomic testing is considered medically necessary in the evaluation of any of the following conditions:
Each bulleted clinical indication is sufficient to consider testing as medically necessary per the policy.
Quantitative pupillometry/pupillography (for example, the NeurOptics NPi-100 Pupillometer) is explicitly considered unproven and NOT COVERED. The policy states there is insufficient evidence in the published, peer‑reviewed medical literature to support the clinical use of these hand‑held infrared pupillometry devices, and therefore they are excluded from coverage.
More broadly, the policy emphasizes that autonomic testing performed using automated devices with software‑generated interpretations (examples listed include ANSAR ANX 3.0, SUDOSCAN, VitalScan, Neuropad, EZScan, and electrochemical skin conductance [ESC]) lacks validation and is likewise considered unproven and NOT COVERED.
Providers should note that these exclusions sit alongside the plan’s general exclusions for experimental, investigational, or unproven services as described in member certificates; benefit‑specific limits and prior authorization requirements may still apply and supersede this policy where indicated.
Coverage excludes services, procedures, and technologies that are determined to be experimental, investigational, or unproven under the member’s certificate. Unproven services delivered outside of an approved clinical trial are specifically excluded. This policy does not expand coverage to include items or services that are specifically excluded by the member’s contract.
Providers should verify member eligibility and contract‑specific benefits prior to delivering services, since line‑of‑business coverage statements and applicable Medicare LCD/NCD guidance may supersede the policy and affect prior authorization requirements.
In addition to quantitative pupillometry and automated interpretation devices, the policy lists other autonomic tests and uses that are considered not medically necessary / not covered because of insufficient evidence. These include the Quantitative pilomotor axon reflex test (QPART) and use of autonomic testing for the following conditions: myofascial pain syndrome/fibromyalgia, Raynaud’s phenomenon, predicting foot ulcers, flushing syndrome, chronic fatigue syndrome, generalized hyperhidrosis, palmoplantar hyperhidrosis, irritable bowel syndrome, somatization disorder, and anxiety disorder.
The policy notes that these tests and indications lack adequate peer‑reviewed evidence to establish clinical value and are therefore excluded from coverage.
During the most recent revision, the policy was updated to add an explicit exclusion for quantitative pupillometry and to clarify unproven language for automated autonomic testing devices. The document states these techniques have insufficient supporting evidence and are therefore considered unproven and not covered.
As with other exclusions, this revision reiterates that experimental, investigational, or unproven services remain excluded under the member’s certificate and that prior authorization and benefit‑specific rules may apply.
Coding Related to Autonomic Testing
| 95919 | Quantitative pupillometry with physician or qualified health care professional interpretation and report, unilateral or bilateral |
| 95921 | Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including two or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio |
| 95922 | 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 | sudomotor, including one or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential |
| 95924 | combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt |
| 95943 | Simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic function, based on time-frequency analysis of heart rate variability concurrent with time-frequency analysis of continuous respiratory activity, with mean heart rate and blood pressure measures, during rest, paced (deep) breathing, Valsalva maneuvers, and head-up postural change |
Provider Actions, Authorization & Documentation
Verify benefits and prior authorization
Verify member eligibility and contract-specific benefits, limitations, and exclusions before ordering autonomic testing; line-of-business benefit documents and applicable Medicare LCDs/NCDs supersede this policy.
- Confirm member eligibility and benefits for the requested service.
- Review the member's line-of-business benefit document for coverage statements that supersede this policy.
- For Medicare members, verify applicable Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
Prior authorization requirement — check member benefit documents
Prior authorization or precertification may be required for autonomic testing; check the member's contract specific benefit document and Geisinger prior authorization resources before performing services.
- Consult the member's contract-specific precertification lists for prior authorization requirements.
- Check Geisinger's provider prior authorization site: https://www.geisinger.org/health-plan/providers/ghp-clinical-policies
Confirm medical indication and authorization before testing
Document the clinical indication supporting the test and ensure benefit and authorization checks are completed prior to scheduling; verify that the requested test aligns with an accepted medically necessary indication per policy.
- Record the specific clinical indication that makes autonomic testing medically necessary.
- Confirm prior authorization/benefit verification was completed and documented in the patient record.
Stop if member's benefit does not cover the service
If the member's benefit document or line-of-business coverage statement does not cover the requested autonomic test, do not proceed without obtaining an authorization or alternate coverage — requests may be denied if not covered by the member's contract.
- Coverage statements in the line-of-business benefit document supersede this policy; obtain authorization only if the benefit allows coverage.
- For Medicare, ensure compliance with LCD/NCD coverage rules to avoid denials.
Coding and documentation guidance — record CPT code and clinical indication
Document the specific autonomic test(s) performed using CPT codes and the clinical indication in the medical record; the listed CPT codes are informational and inclusion does not guarantee coverage.
- List the CPT code(s) that correspond to the test performed (e.g., 95921, 95922, 95923, 95924, 95943, 95919) in the report.
- Include the clinical reason for testing and any supporting findings in the record.
- Note that Medicare may only cover specific CPT codes per CMS rules; consult CMS or the local MAC for Medicare coding guidance.
Precertification / prior authorization — consult benefit document
Consult the member's contract specific benefit document for any precertification/prior authorization requirements; prior authorization information is available on Geisinger's provider site.
- Check precertification lists within the member's contract-specific benefit document.
- Access Geisinger prior authorization resources: https://www.geisinger.org/health-plan/providers/ghp-clinical-policies
Coverage limited by member benefit documents and Medicare rules
Requests for autonomic testing may be denied if the member's certificate, line-of-business benefit document, or applicable Medicare LCD/NCD excludes the service — verify coverage prior to service.
- Coverage statements in the line-of-business benefit document supersede this policy and may result in denial.
- For Medicare members, applicable LCDs and NCDs will supersede this policy and can affect coverage determinations.
Experimental, investigational, or unproven services are excluded
Services that are experimental, investigational, or unproven are specifically excluded under the member's certificate; quantitative pupillometry and other listed unproven tests are not covered outside an approved clinical trial.
- Quantitative pupillometry/pupillography (e.g., NeurOptics NPi-100 Pupillometer) and automated devices with software-generated interpretations are considered unproven and not covered.
- Unproven services outside of an approved clinical trial are excluded per the member's certificate and policy MP015.
Background on Autonomic Testing
Autonomic testing assesses multiple domains of autonomic nervous system function, typically grouped into cardiovagal (parasympathetic), vasomotor/adrenergic (sympathetic), and sudomotor evaluations. Commonly used tests include measures of heart rate variability and reflexes for cardiovagal function, blood pressure and R‑R interval responses for vasomotor/adrenergic function (including tilt testing and Valsalva), and quantitative sudomotor assessments such as QSART, thermoregulatory sweat testing, or other measures of sweat production.
These tests are used to diagnose and assess the severity and distribution of autonomic neuropathies, evaluate orthostatic hypotension and syncope variants, help differentiate certain neurodegenerative synucleinopathies, and to evaluate conditions such as postural tachycardia syndrome when clinically indicated.
Definitions
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