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Clinical Policy Title: Autonomic nervous system monitoring for neuropathy

Clinical Policy Number: 09.01.01

Effective Date: September 1, 2013

Initial Review Date: February 18, 2013

Most Recent Review Date: April 10, 2018

Next Review Date: April 2019

Related policies:

09.01.13 Tilt table testing

ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.

Coverage policy

AmeriHealth Caritas considers the use of autonomic nervous system monitoring for neuropathy to be

clinically proven and, therefore, medically necessary when overseen and interpreted by a physician of

the appropriate specialty (neurologist or cardiologist) and when any of the following goals of

monitoring are met:

To diagnose the presence of autonomic neuropathy in a patient with signs or symptoms

suggesting a progressive autonomic neuropathy.

To evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy.

To differentiate the diagnosis between certain complicated variants of syncope from other

causes of loss of consciousness.

To evaluate inadequate response to beta blockade in vasodepressor syncope.

To evaluate distressing symptoms in a patient with a clinical picture suspicious for distal small

fiber neuropathy in order to diagnose the condition.

To differentiate the cause of postural tachycardia syndrome.

To evaluate a change in type, distribution, or severity of autonomic deficits in patients with

autonomic failure.

Policy contains:

Autonomic nervous system.

Diabetes.

Neuropathy.

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To evaluate the response to treatment in patients with autonomic failure who demonstrate a

change in clinical exam.

To diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient.

To evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic

failure, after more common causes have been excluded by other standard testing (LCD L35395).

Limitations:

All other uses of autonomic nervous system monitoring for neuropathy are not medically necessary.

Alternative covered services:

Physician office visits.

Appropriate therapy sessions.

Background

Dysfunction of the autonomic nervous system, including neuropathy, may involve conditions that

affect either the sympathetic or parasympathetic nerves. The resulting deregulation may be

clinically insignificant or may manifest as a number of symptoms based upon the body organs

affected. Symptoms can include irregular heart rate, blood pressure, body temperature,

perspiration, and bowel and bladder functions. Other symptoms include fatigue, lightheadedness,

feeling faint or passing out (syncope), weakness, and cognitive impairment (Mayo Clinic, 2018).

An autonomic nervous system dysfunction that affects the cardiovascular system may result in either

rapid resting or slowing heart rate. Blood pressure may drop on standing, a condition called

“orthostatic hypotension.” Any cardiovascular effects may result in syncope, or loss of consciousness.

An autonomic nervous system dysfunction affecting other organs may result in genitourinary

symptoms (e.g., urinary incontinence, erectile dysfunction, or incomplete voiding/neurogenic bladder);

gastrointestinal symptoms (gastroparesis, diarrhea, or constipation); sweating problems with excessive

or inadequate sweat production that can affect body temperature control; or vision difficulties from

inappropriate pupillary constriction.

Autonomic nervous system neuropathy may be caused by a patient’s symptoms, general health, family

history, recent or current medications, exposure to poisons, alcohol consumption, or sexual history.

These factors should be assessed by the attending physician. Checking the skin, pulse, sensation, and

reflexes may also offer clues in the diagnosis of autonomic nervous system neuropathy. Diagnosis can be

made through nerve conduction studies that check speed of the nerves sending messages, through

electrodes placed on the skin over the nerves; electromyography in which a thick needle is inserted into

the skin and muscle and an oscilloscope is used to stimulate the nerves; or nerve and skin biopsies.

A number of diseases may account for autonomic nervous system dysfunction. Autonomic neuropathy is

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an important, but not well-recognized complication of diabetes. Its clinical manifestations include

orthostatic hypotension, exercise intolerance, gastroparesis, diarrhea, constipation, and urinary

incontinence. The disorder is linked with sudden unexplained deaths in young people, even though the

condition is relatively rare. In diabetic adults, autonomic neuropathy is a strong predictor of mortality,

mostly due to cardiovascular disease, nephropathy, and hypoglycemia (Tang, 2013).

Autonomic nervous system testing includes three domains:

Cardiovagal innervation is a test that provides a standardized quantitative evaluation of vagal

innervation to parasympathetic function of the heart. Responses are based on the

interpretation of changes in continuous heart recordings in response to standardized

maneuvers and include heart rate response to deep breathing, Valsalva ratio, and 30:15 ratio

heart rate responses to standing. A tilt table may be used, but is not required.

Vasomotor adrenergic innervation evaluates adrenergic innervation of the circulation and of

the heart in autonomic failure. The following tests are included: beat-to-beat blood pressure

and R-R interval response to Valsalva maneuver, sustained hand grip, and blood pressure and

heart rate responses to tilt-up or active standing and must be performed with a tilt table.

Sudomotor is tests functions to evaluate and document neuropathic disturbances that may

be associated with pain. The quantitative sudomotor axon reflex test, thermoregulatory

sweat test, sympathetic skin responses, and silastic sweat imprints are tests of sympathetic

cholinergic sudomotor function LCD (L35124).

Searches

AmeriHealth Caritas searched PubMed and the databases of:

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other

evidence-based practice centers.

The Centers for Medicare & Medicaid Services (CMS).

We conducted searches on February 11, 2018. Search terms were: “autonomic nervous system” and

“neuropathy.”

We included:

Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and

greater precision of effect estimation than in smaller primary studies. Systematic reviews use

predetermined transparent methods to minimize bias, effectively treating the review as a

scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

Guidelines based on systematic reviews.

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Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost

studies), reporting both costs and outcomes — sometimes referred to as efficiency studies —

which also rank near the top of evidence hierarchies.

Findings

An American Academy of Neurology practice parameter found that autonomic testing should be

considered in evaluating patients with polyneuropathy to document autonomic nervous system

involvement and suspected autonomic neuropathies. Both applications were given a level “B” grade by

the expert panel (American Academy of Neurology, 2009).

A publication from the National Heart, Lung, and Blood Institute asserted that autonomic nervous

system function is assessed by measuring resting heart rate, heart rate variability, or heart rate

recovery after exercise. These measures can identify correlates of autonomic nervous system

dysfunction for patients, such as obesity, diabetes, and heart failure (Lauer, 2009).

Recommendations from the Neuropathy Study Group of the Italian Society of Diabetology were

produced because diabetic autonomic neuropathy is not often diagnosed. These recommendations

include information on how and when to perform the recommended tests, and how to interpret them

(Spallone, 2011).

A Hayes review from 2014 assessed 23 studies (n = 6,141) on autonomic nervous system monitoring for

neuropathy. Diabetes was the topic of 17 of these studies, and 20 of 23 focused on adults. The types of

tests included cardiovascular tests, nerve and muscle fiber conduction tests, sudomotor function tests,

peripheral sensory perception threshold tests, laser Doppler skin blood flow studies, pupillary function

tests, gastric emptying tests, and serum autonomic neurotransmitter tests. The proportion of

abnormalities in persons with a disorder versus healthy persons were compared for each. Hayes rated

the efficacy of most tests as “moderate” when sufficient data were available (Hayes, 2014).

Diabetic autonomic neuropathy is common among diabetics, and raises the morbidity and mortality

risk in older adults as it often goes undiagnosed and untreated (Scheinberg, 2016). One study of 151

type 1 diabetes patients assessed the association of various risk factors to the disease. These included

neuropathy and diabetic neuropathy; both were highly significant predictors of the disease (Tannus,

2014). Another review found an under-diagnosis of cardiovascular autonomic neuropathy in persons

with diabetes due to low interest in an unfamiliar complication, skepticism of therapies, lack of

understanding diagnostic utility, and need for education and training — in spite of evidence of

predictive value of neuropathy for the disease. A related issue is the lack of uniformity of treatment

(Rolim, 2013).

A study of 490 persons ages 50 – 75 with diabetes followed for a median of 13.6 years found that

cardiac autonomic dysfunction, described using 10 measures, was strongly associated with a risk of

cardiovascular mortality. The study recommended such measures be monitored in persons with

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diabetes (Beijers, 2009). A related article found that the impact of hypoglycemia on cardiovascular

autonomic function could explain the risk of cardiovascular mortality among persons with diabetes

(Adler, 2009). Another study documented that more persons with diabetes on intensive therapy had

neuropathy than those on standard therapy (Duckworth, 2009).

Risk factors for cardiac autonomic neuropathy were analyzed in a meta-analysis of four studies (n =

1,755). Factors that significantly raised risk included age, duration of diabetes, body mass index,

proliferative retinopathy, microalbuminuria, hypertension, systolic and diastolic blood pressure,

HbA1C, triglycerides, and high-density lipoprotein cholesterol. Findings allow practitioners to identify

persons with diabetes at high risk of developing cardiac autonomic neuropathy (Dafaalla, 2016).

A systematic review of 18 (n = 6,915) retrospective and prospective cohort studies addressed

monitoring of invasive and non-invasive heart rate variability — potentially a useful tool in addition to

conventional autonomic tests — in intensive care units. Results included increases in mortality

associated with reduction in variability (entropy 0.65 versus 0.84, p < 0.05); reduction in the baroreflex

(transfer) function (0.43 versus 1.11, p < 0.05); sustained reduction of the low frequency/high

frequency ratio (0.22 versus 0.62 p < 0.01); loss of heart rate volatility during the first 24 hours of

hospitalization; and reduction in variability in patients admitted to intensive care after cardiac arrest

and undergoing therapeutic hypothermia (Bento, 2017).

Individuals with the metabolic syndrome have alterations in the function of the autonomic nervous

system, and these alterations are linked with greater risk of aspects of the syndrome, such as obesity,

hypertension, and insulin resistance — although the issue of whether these alterations are contributors

or a consequence of the syndrome remains unresolved (Licht, 2010).

Patients with obstructive sleep apnea have increased levels of sympathetic activity, resulting in

autonomic nervous system imbalance, potentially predisposing them to greater risk of cardiac

arrhythmias (Aytemir, 2007).

Some new monitors have been developed to track autonomic nervous system activity. One pleth-wave

derived parameter, the Perfusion Index, was tested on 20 patients, and index modifications occurred

(Del Buono, 2016). Another monitor is a low-power, generic, small wireless sensor node to monitor

physiological signals of responses of the autonomic nervous system (Brown, 2009).

Policy updates:

A total of one clinical guideline/other and three peer-reviewed references were added to, and one

peer-reviewed reference was removed from, the policy in February 2018.

Summary of clinical evidence:

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Citation Content, Methods, Recommendations

Bento (2017) Monitoring heart rate variability

Key points:

Systematic review of 18 (n = 6,915) retrospective and prospective cohort studies.

Analyzed monitoring of heart rate variability — potentially a useful tool in addition to conventional autonomic tests — in intensive care units.

Results included increases in mortality associated with reduction in variability (entropy 0.65 versus 0.84, p < 0.05); reduction in the baroreflex (transfer) function 0.43 versus 1.11, p < 0.05); sustained reduction of the low frequency/high frequency ratio (0.22 versus 0.62 p < 0.01); loss of heart rate volatility during the first 24 hours of hospitalization; and reduction in variability in patients admitted to intensive care after cardiac arrest and undergoing therapeutic hypothermia.

Heart rate variability varies inversely with clinical severity and prognosis.

Dafaalla (2016) Risk factors of cardiac autonomic neuropathy in type 1 diabetes mellitus

Key points:

Meta-analysis of four studies (n = 1,755) on risk factors for cardiac autonomic neuropathy.

Factors that significantly raised risk included age, duration of diabetes, body mass index, proliferative retinopathy, microalbuminuria, hypertension, systolic and diastolic blood pressure, HbA1C, triglycerides, and HDL cholesterol.

Findings allow practitioners to identify diabetics at high risk of developing cardiac autonomic neuropathy.

Hayes (2014) Evaluation of tests for ANS monitoring for neuropathy

Key points:

Literature review of 23 studies (n = 6,141); diabetics were the subject in 17 of 23 adults were the subject in 20 of 23.

Tests included cardiovascular tests, nerve and muscle fiber conduction tests, sudomotor function tests, peripheral sensory perception threshold tests, laser Doppler skin blood flow studies, pupillary function tests, gastric emptying tests, and serum autonomic neurotransmitter tests.

Efficacy of most tests was rated “moderate”; some tests had insufficient data, and were not rated.

Beijers (2009) Cardiovascular autonomic function hazards In diabetics

Key points:

Study of 490 diabetics ages 50 – 75, followed for 13.6 years (median).

10 parameters of cardiovascular autonomic dysfunction graded for each subject.

Cardiovascular autonomic dysfunction significantly raised risk of cardiovascular mortality (risk ratio = 1.74).

American Academy of Neurology (2009) Guideline on diagnosing distal symmetric polyneuropathy

Key points:

Role of autonomic testing, nerve biopsy, and skin biopsy in diagnosing distal symmetric polyneuropathy.

Autonomic testing should be considered in evaluating patients with suspected autonomic neuropathies.

Autonomic testing should be considered in evaluating patients with polyneuropathy to document autonomic nervous system involvement.

References

Professional society guidelines/other:

American Academy of Neurology. The role of autonomic testing, nerve biopsy, and skin biopsy in

diagnosing distal symmetric polyneuropathy. AAN, 2009. Summary of evidence-based guidelines for

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clinicians. https://www.aan.com/Guidelines/Home/GetGuidelineContent/317. Accessed February 11,

2018.

Brown L, et al. Body area network for monitoring autonomic nervous system responses. In: Pervasive

Computing Technologies for Healthcare, 2009. PervasiveHealth 2009. 3rd International Conference; 1 –

3.

England JD, Gronseth S, Franklin G, et al. Practice parameter: evaluation of distal symmetric

polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review).

Report of the American Academy of Neurology, American Association of Neuromuscular and

Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation.

Neurology. 2009;72(2):177 – 84.

Mayo Clinic. Neurology Research: Autonomic Nerve Disorders. Rochester MN: Mayo Clinic,

Department of Neurology, 2018. http://www.mayo.edu/research/departments-divisions/department-

neurology/programs/autonomic-nerve-disorders. Accessed February 11, 2018.

Spallone V, Bellavere F, Scionti L, et al. Recommendations for the use of cardiovascular tests in

diagnosing diabetic autonomic neuropathy. Nutr Metab Cardiovasc Dis. 2011;21(1):69 – 78.

Peer-reviewed references:

Adler GK, Bonyhay I, Failing H, et al. Anteccedent hypoglycemia impairs autonomic cardiovascular

function: implications for rigorous glycemic control Diabetes. 2009;58:360 – 66.

Aytemir K, Deniz A, Yavuz B, et al. Increased myocardial vulnerability and autonomic nervous system

imbalance in obstructive sleep apnea syndrome. Respir Med. 2007;101:1277 – 82.

Beijers HJ, Ferreira I, Bravenboer B, et al. Microalbuminuria and cardiovascular autonomic dysfunction

are independently associated with cardiovascular mortality: evidence for distinct pathways: the Hoorn

Study. Diabetes Care. 2009;32(9):1698 – 703.

Bento L, Fonseca-Pinto R, Povoa P. Autonomic nervous system monitoring in intensive care as a

prognostic tool. Systematic review. Rev Bras Ter Intensiva. 2017;29(4):481 - 89.

Bremner F, Smith S. Pupillographic findings in 39 consecutive cases of harlequin syndrome. J

Neuroophthalmol. 2008;28(3):171 – 77.

Casellini CM, Parson HK, Richardson MS, Nevoret ML, Vinik AI. Sudoscan, a noninvasive tool for

detecting diabetic small fiber neuropathy and autonomic dysfunction. Diabetes Technol Ther.

2013; 15(11):948 – 53.

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Dafaalla MD, Nimir MN, Mohammed MI, Ali OA, Hussein A. Risk factors of diabetic cardiac autonomic

neuropathy in patients with type 1 diabetes mellitus: a meta-analysis. Open Heart. 2016;3(2):e000336.

Del Buono R, Cappiello D, Pascarella G, Agro FE. The monitoring of the autonomic nervous system: myth

or reality. J Clin Anesth Manag, 2016;1(4). Doi: 10.16966/2470-9956.116.

https://www.sciforschenonline.org/journals/clinical-anesthesia/JCAM-1-116.php. Accessed February 11,

2018.

Duckworth W, Abraire C, Moritz T, et al. Glucose control and vascular complications inveterans

with type 2 diabetes. N Engl J Med. 2009;360:129 – 39.

Figueroa JJ, Dyck PJ, Laughlin RS, et al. Autonomic dysfunction in chronic inflammatory

demyelinating polyradiculoneuropathy. Neurology. 2012;78(10):702 – 08.

Griffith KA, Couture DJ, Zhu S, et al. Evaluation of chemotherapy-induced peripheral neuropathy using

current perception threshold and clinical evaluations. Support Care Cancer. 2014;22(5):1161 – 69.

Hayes Inc., Hayes Medical Technology Report. Autonomic nervous system monitoring for

neuropathy. Lansdale, PA: Hayes Inc.; updated February 2014.

Illigens BM, Gibbons CH. Sweat testing to evaluate autonomic function. Clin Auton Res. 2009;19(2):79 –

87.

Lauer MS. Autonomic function and prognosis. Cleve Clin J Med. 2009;76 Suppl 2:S18 – 22.

Licht CM, Vreeburg SA, van Reedt Dortland AK, et al. Increased sympathetic and decreased

parasympathetic activity rather than changes in hypothalamic-pituitary-adrenal axis activity is associated

with metabolic abnormalities. J Clin Endocrinol Metab. 2010;945:2458 – 66.

Low P, Tomalia V, Park KJ. Autonomic functions tests: Some clinical applications. J Clin Neurol. 2013;9(1):

1 – 8.

Rolim LC, de Souza JST, Dib SA. Tests for early diagnosis of cardiovascular autonomic neuropathy; critical

analysis and relevance. Front Endocriniol. 2013;4(173). Doi: 10.3389/fendo.2013.00173.

Scheinberg N, Salbu RL, Goswami G, Cohen K. Treatment of diabetic autonomic neuropathy in older

adults with diabetes mellitus. Consult Pharm. 2016;31(11):633 – 45.

Tang M, Donaghue KC, Cho YH, Craig ME. Autonomic neuropathy in young people with type 1

diabetes: a systematic review. Pediatr Diabetes. 2013;14(4):239 – 48.

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Tannus LRM, Drummond KRG, Clemente ELsaS, Gomes MB. Predictors of cardiovascular

autonomic neuropathy in patients with type 1 diabetes. Frontiers in Endocrinology. 2014;5(191).

Vinik AI, Nevoret M, Casellini C, Parson H. Neurovascular function and sudorimetry in health and

disease. Curr Diab Rep. 2013;13(4):517 – 32.

Vinik AI, Maser RE, Ziegler D. Autonomic imbalance: prophet of doom or scope for hope? Diabet Med.

2011;28(6):643 – 51.

CMS National Coverage Determinations (NCDs):

70.2.1 Services provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with

Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy). Effective July 1, 2002.

https://www.cms.gov/medicare-coverage-database/details/ncd-

details.aspx?NCDId=171&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&

s=All&KeyWord=neuropathy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAA

AAAAA%3d%3d&. Accessed February 11, 2018.

Local Coverage Determinations (LCDs):

Autonomic Function Testing

L36236 Autonomic Function Testing. National Government Services, Inc. Effective October 1, 2015. .

https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=36236&ver=14&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=A

ll&KeyWord=autonomic+function+testing&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gA

AAACAAAAAA&. Accessed February 11, 2018.

L35124 Autonomic Function Testing. Wisconsin Physician Service Insurance

Corporation. Effective October 1, 2015. . https://www.cms.gov/medicare-coverage-

database/details/lcd-

details.aspx?LCDId=35124&ver=14&CoverageSelection=Both&ArticleType=All&PolicyT

ype=Final&s=All&KeyWord=autonomic+function+testing&KeyWordLookUp=Title&Key

WordSearchType=And&bc=gAAAACAAAAAA&. Accessed February 11, 2018.

L35395 Autonomic Function Tests Novitas Solutions, Inc. Effective October 1, 2015.

https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=35395&ver=40&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&

KeyWord=autonomic+function+test&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAA

AAAA&. Accessed February 11, 2018.

Autonomic Nervous System.

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L35456 Nerve Blockade for Treatment of Chronic Pain and Neuropathy. Noridian Healthcare Solutions

LLC. Effective October 1, 2015. https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=35456&ver=39&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&

KeyWord=neuropathy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&.

Accessed February 11, 2018.

L35457 Nerve Blockade for Treatment of Chronic Pain and Neuropathy. Noridian Healthcare Solutions

LLC. Effective October 1, 2015. https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=35457&ver=36&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&

KeyWord=neuropathy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&.

Accessed October 1, 2015.

L35249 Nerve Blocks for Peripheral Neuropathy. CGS Administrators, LLC. Effective October 1, 2015.

https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=35249&ver=4&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&K

eyWord=neuropathy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&.

Accessed February 11, 2018.

L35222 Nerve Blocks for Peripheral Neuropathy. Wisconsin Physicians Service Insurance Corporation.

Effective October 1, 2015. https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=35222&ver=11&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&

KeyWord=neuropathy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&.

Accessed February 11, 2018.

L34295 Surgery: Nerve Blocks and Electrostimulation for Peripheral Neuropathy. Cahaba Government

Benefit Administrators® LLC. Effective October 1, 2015. https://www.cms.gov/medicare-coverage-

database/details/lcd-

details.aspx?LCDId=34295&ver=12&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&

KeyWord=neuropathy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&.

Accessed February 11, 2018.

Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is

not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals

and bill accordingly.

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CPT Code Description Comments

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 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

ICD-10 Code Description Comments

E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy

E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication

E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy

E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication

E10.43 Type 1 diabetes mellitus with diabetic autonomic, (poly)neuropathy

E10.49 Type 1 diabetes mellitus with other diabetic neurological complication

E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy

E11.49 Type 2 diabetes mellitus with other diabetic neurological complication

E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy

E13.49 Other specified diabetes mellitus with other diabetic neurological complication

G60.3 Idiopathic progressive neuropathy

G90.1 Familial dysautonomia (Riley-Day Syndrome)

G90.2 Horner's syndrome

G90.3 Shy-Drager Syndrome

G90.4 Autonomic dysreflexia

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ICD-10 Code Description Comments

G90.8 Other disorders of autonomic nervous system

G90.9 Disorder of the autonomic nervous system, unspecified

HCPCS Level II Code

Description Comment

N/A