CurrentNetwork HealthPolicy n05706

Autonomic Nervous System Testing

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This policy guides Network Health medical-necessity decisions for autonomic nervous system testing for commercial and Medicare Advantage members. Medicare Advantage coverage follows applicable CMS National and Local Coverage Determinations, while commercial coverage is subject to the member's applicable benefit documents.

Policy Summary

PayerNetwork Health

PolicyAutonomic Nervous System Testing

Policy CodePolicy n05706

Change TypeAnnual reviewno material clinical or coverage change

Effective DateN/A

Last ReviewAug 20, 2026

Next Review DateAug 20, 2027

Key ActionFor recurrent unexplained syncope, document an inconclusive initial complete history and physical examination and ECG.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review documented grammatical and formatting changes and reference updates.

7Medical-necessity indication categories

12Experimental or investigational indication examples

3CPT codes listed

4Sudomotor testing methods defined

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CurrentNetwork HealthPolicy n05706

Autonomic Nervous System Testing

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Policy Summary

PayerNetwork Health

PolicyAutonomic Nervous System Testing

Policy CodePolicy n05706

Change TypeAnnual reviewno material clinical or coverage change

Effective DateN/A

Last ReviewAug 20, 2026

Next Review DateAug 20, 2027

Key ActionFor recurrent unexplained syncope, document an inconclusive initial complete history and physical examination and ECG.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review documented grammatical and formatting changes and reference updates.

7Medical-necessity indication categories

12Experimental or investigational indication examples

3CPT codes listed

4Sudomotor testing methods defined

2Lines of business addressed

Medical Necessity Coverage Criteria

Medically Necessary Indications

Cardiovagal, sudomotor (QSART, SSR, and TST), and vasomotor adrenergic autonomic testing is considered medically necessary when performed for any of the following indications:

ONE of the following indications

Distal small fiber neuropathy
Postural orthostatic tachycardia syndrome
Progressive autonomic neuropathy, including ONE of the following
- Amyloid neuropathy
- Diabetic neuropathy
- Idiopathic neuropathy
- Multiple system atrophy
- Pure autonomic failure
- Sjogren's neuropathy
Recurrent unexplained syncope with documentation of an inconclusive initial complete history and physical examination and electrocardiogram (ECG)
Reflex sympathetic dystrophy or complex regional pain syndrome (CRPS), including sympathetically maintained pain or causalgia
Evaluation of a change in the type, distribution, or severity of autonomic deficits in a member with autonomic failure
Evaluation of response to treatment in a member with autonomic failure who demonstrates a change in clinical examination

Autonomic nerve testing using portable, automated devices is considered experimental and investigational.

The following autonomic nervous system tests are considered experimental and investigational: TM-FLOW, EZSCAN, quantitative direct and indirect reflex testing (QDIRT), quantitative pilomotor axon reflex test (QPART), ambulatory autonomic nervous system monitors, and Sudoscan. This list may not be all inclusive.

Screening members without signs or symptoms of autonomic dysfunction is not considered medically necessary, including screening of members with diabetes, hepatic disease, or renal disease.

Testing performed solely to monitor disease intensity or treatment efficacy in diabetes, hepatic disease, or renal disease is not considered medically necessary.

Coding and Testing Specifications

CPT CodesCPT

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.
95923	Testing of autonomic nervous system function, sudomotor including 1 or more of the following: Quantitative sudomotor axon reflex test (QSART), Silastic sweat imprint, thermoregulatory sweat test, and changing in sympathetic skin potential.

Passive Tilt Requirement

Minimum durationAt least 5 minutes of passive tilt

Associated assessmentBeat-to-beat blood pressure and R-R interval changes during the Valsalva maneuver

Related CPT code95922 — vasomotor adrenergic innervation testing

Cardiovagal Testing Components

Minimum components2 or more specified cardiovagal testing components

Deep breathing responseHeart-rate response to deep breathing with recorded R-R interval

Valsalva assessment

Documentation and Provider Guidance

Documentation Required

Document an Inconclusive Initial Syncope Workup

For recurrent unexplained syncope, document that the initial complete history and physical examination and ECG were inconclusive before ordering autonomic nervous system testing.

Include the clinical history and physical examination findings.
Include the ECG results and explain why the initial evaluation was inconclusive.

Documentation Required

Document Clinical Examination Change

When testing is used to evaluate response to treatment in a member with autonomic failure, document a change in the clinical examination.

Describe the pre-treatment clinical examination.
Describe the documented post-treatment change and relate it to the treatment response being evaluated.

Autonomic Nervous System Testing

Autonomic nervous system testing evaluates sympathetic and parasympathetic function. Cardiovagal testing assesses parasympathetic function through heart-rate variability during deep breathing, the Valsalva maneuver, and standing. Vasomotor adrenergic testing evaluates sympathetic function and is used in conditions such as syncope, orthostatic hypotension, postural tachycardia syndrome, and postural dizziness. Sudomotor testing evaluates and documents neuropathic disturbances that may be associated with pain.

Testing Definitions

Sudomotor Testing

PurposeEvaluates and documents neuropathic disturbances that may be associated with pain

QSARTSudomotor axon reflex test (QSART)

Silastic sweat imprintSilastic sweat imprint (SSI)

Thermoregulatory methodThermoregulatory sweat test (TST)

Additional methodSympathetic skin response (SSR)

Cardiovagal Autonomic Testing

Function assessedParasympathetic function

Policy Summary

PayerNetwork Health

PolicyAutonomic Nervous System Testing

Policy CodePolicy n05706

Change TypeAnnual reviewno material clinical or coverage change

Effective DateN/A

Last ReviewAug 20, 2026

Next Review DateAug 20, 2027

Key ActionFor recurrent unexplained syncope, document an inconclusive initial complete history and physical examination and ECG.

SourceLink

On This Page

Standing response30:15 ratio

Sudomotor Testing Components

Minimum components1 or more specified sudomotor testing components

QSARTQuantitative sudomotor axon reflex test

Silastic sweat imprintSilastic sweat imprint

Thermoregulatory testingThermoregulatory sweat test

Sympathetic skin responseChanging sympathetic skin potential

Denial Risk

Unlisted Indications Are Experimental

Autonomic testing for indications outside the medically necessary list is considered experimental and investigational.

Examples include 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 predicting foot ulcers.

Denial Risk

Portable Automated Devices Are Experimental

Autonomic nerve testing performed with portable, automated devices is considered experimental and investigational.

Confirm that the testing method is not a portable automated device before submitting a claim.

Denial Risk

Asymptomatic Screening Is Not Medically Necessary

Screening members without signs or symptoms of autonomic dysfunction is not medically necessary, including screening of members with diabetes, hepatic disease, or renal disease.

Document signs or symptoms of autonomic dysfunction when testing is ordered.

Denial Risk

Disease-Monitoring Testing Is Not Medically Necessary

Testing performed solely to monitor disease intensity or treatment efficacy in diabetes, hepatic disease, or renal disease is not medically necessary.

The testing must have a covered diagnostic purpose rather than disease monitoring alone.

Denial Risk

Experimental Testing Methods

The following autonomic nervous system testing methods are considered experimental and investigational: TM-FLOW, EZSCAN, QDIRT, QPART, ambulatory autonomic nervous system monitors, and Sudoscan. The list may not be all-inclusive.

TM-FLOW
EZSCAN
Quantitative direct and indirect reflex testing (QDIRT)
Quantitative pilomotor axon reflex test (QPART)
Ambulatory autonomic nervous system monitors
Sudoscan

Measurement methodMeasures heart-rate variability via electrocardiogram

Testing conditionsAssessment is performed during deep breathing, the Valsalva maneuver, and standing

Interpretive findingA decrease in heart rate shows parasympathetic dysfunction

Vasomotor Adrenergic Autonomic Testing

Function assessedSympathetic adrenergic function

Primary usePrimary test for members with syncope, orthostatic hypotension, postural tachycardia syndrome, and postural dizziness

Clinical roleEvaluates vasomotor adrenergic function