Currentpriority healthPolicy N/A

Autonomic Function Testing Billing

This billing policy governs reimbursement, coding, documentation, and frequency guidelines for autonomic nervous system function tests performed for Priority Health members, and affects providers submitting claims and seeking authorization for these services.

Policy Summary

Payerpriority health

PolicyAutonomic Function Testing Billing

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 11, 2025

Next Review DateMay 20, 2026

Key ActionFor Medicare indications that do not meet NCD/LCD or specific policy, obtain a Pre-Service Organization Determination (PSOD) per the Provider Manual.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

95921-95924CPT range covered

once/yrFreq. limit

requiredPSOD

ASC: INASC indicator

Medical Necessity and Coverage Criteria

Medical necessity, frequency, review, and documentation

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Diagnostic testing may be allowed once to confirm or exclude specific autonomic diseases; for patients with diagnosed autonomic disorders, repeat testing is permitted only for change in clinical status or response to therapeutic intervention and is not expected to exceed once per year.

Providers performing these tests at an unusually high frequency or on an unusually high proportion of their patients may be subject to medical review.

Providers who do not have tilt tables and are using CPT codes 95921-95924 may be subject to medical review.

Medical record documentation maintained by the performing provider must clearly support the medical necessity for autonomic nervous system (ANS) testing, including test reports and interpretation. Documentation should include relevant medical history, physical examination, and results of diagnostic tests or procedures used to rule out more common causes of autonomic signs or symptoms.

Coverage will be considered when services are furnished in the setting appropriate to the patient’s medical needs and condition; authorization may be required per the Provider Manual.

CPT Codes and Frequency Limits

Autonomic function CPT codesCPTCovered

95921-95924

Testing of autonomic nervous system function (cardiovagal, vasomotor adrenergic, sudomotor, combined)

Frequency limit — Repeat testing

Frequency limitRepeat testing generally not expected to exceed once per year unless there is a change in clinical status or response to therapy

Reason for repeat testingAllowed to evaluate change in clinical status or response to therapeutic intervention

Medical review riskProviders performing tests at frequencies exceeding once per year or on an unusually high proportion of patients may be subject to medical review

Pre-Service Determination and Authorization

Prior Authorization

Pre‑Service Organization Determination (PSOD) and authorization required for certain Medicare indications

For Medicare indications that do not meet an NCD, local LCD, or specific medical policy, the provider must obtain a Pre‑Service Organization Determination (PSOD) prior to furnishing services. Additionally, coverage will be considered only when services are furnished in the appropriate setting to the patient's medical needs and condition; authorization may be required per the Provider Manual.

Complete a PSOD for Medicare indications that fall outside NCD/LCD or specific medical policy.
Confirm whether prior authorization is required based on place of service and patient needs by consulting the Provider Manual.

Key Definitions and Code Component Details

Autonomic function tests — definition

DefinitionAutonomic function tests are a series of non-invasive procedures that assess the function of the autonomic nervous system.

PurposeAssess cardiovagal, vasomotor adrenergic, and sudomotor subsystems to evaluate autonomic dysfunction

Typical componentsMay include heart rate response to deep breathing, Valsalva ratio, tilt table testing, QSART and other non-invasive maneuvers

CPT 95921-95924 — components and specifics

Included services (general)Physician interpretation, recording, report, and testing for autonomic dysfunction including site and autonomic subsystems; data storage and display on monitor

95921 (cardiovagal)Testing of autonomic nervous system function; cardiovagal (parasympathetic) including ≥2 of: heart rate response to deep breathing with recorded R‑R interval, Valsalva ratio, and 30:15 ratio; monitoring by ECG

95922 (vasomotor adrenergic)Testing of vasomotor adrenergic innervation (sympathetic) including beat‑to‑beat blood pressure and R‑R interval changes during Valsalva maneuver and ≥5 minutes of passive tilt

95923 (sudomotor)Sudomotor testing including ≥1 of: QSART, silastic sweat imprint, thermoregulatory sweat test, or changes in sympathetic skin potential

95924 (combined)Combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt; includes tilt table testing for adrenergic and parasympathetic assessment