Download ANS – Letter Of Medical necessity

ANS
Cadiovascular Analysis = arterial circulation and compliance  with ECG Analysis
Overactive SNS vs PNS
-
More SNS = increase perception of pain
How does SNS respond to stress?
Test for autonomic balance  sitting/standing, Valsalva, BP
o arterial vascular assessment – tone and velocity
ANS Disorder
-
Orthostatic hypotension, heat intolerance, nausea, constipation, urinary retention/incontinence, nocturia,
impotence and dry mucous membranes
Cardiovagal innervation
o Evaluates heart rate response of beat-to-beat blood pressure – Valsalva or head-up tilt
o Increasing intrathoracic pressure and reduces return  reflex hypertension and increase BP
LifeGuard Scan is diagnostic tool to evaluate symptoms of vasomotor instability for any of the following:

Diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive
autonomic neuropathy, including: Diabetic neuropathy, Amyloid neuropathy, Sjogren’s syndrome, Idiopathic
neuropathy, pure autonomic failure, Multiple system dystrophy.

Evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy;

Differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of
consciousness;

Evaluate inadequate response to beta blockade in vasodepressor syncope;

Evaluate distressing symptoms in the patient with a clinical picture suspicious for distal small fiber neuropathy in
order to diagnose the condition;

Differentiate the cause of postural tachycardia syndrome;

Evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure;

Evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical
exam;

Diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient;

Evaluate and diagnose sympathetically maintained pain, as in reflex sympathetic dystrophy or causalgia; or

Evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic failure.
LifeGuard Scan is able to detect specific types of autonomic dysfunction which can consequently be linked to a multitude
of clinical diagnoses.
LifeGuard Scan can be utilized for thorough, comprehensive assessments and physiological monitoring which provide
physicians with a detailed and thorough patient appraisal which can often be overlooked in standard evaluations.
Heart Rate Variability (HRV) is a measure of the variation in beat-to-beat intervals in heart rate. Heart rate variability
analysis is a powerful tool in assessment of the autonomic function
Higher variations in the heart rate lead to greater heart rate variability which indicates good health and well-balanced
autonomic function
Clinical testing to assess:

Beta-Blocker Responsiveness

COPD

Cardiovascular Autonomic Neuropathy (CAN)

Peripheral Vascular Diseases

Diabetic Autonomic Neuropathy (DAN)

Ortostatic Hypotension

Cardiomyopathies

Circulation Problems

Cardiac Arrhythmias

Pain Management

Congestive Heart Failure

Neurological Conditions

Syncope

Chronic Regional Pain Syndrome

Hypertension

Anxiety/Stress

Sleep Apnea

Parkinson's Disease

Asthma

Psychological Conditions

Sudden Death

Other Hidden Diseases
How it Helps?

Evaluation of current health situation - symptoms, medications and therapy reactions;

Assessment of possible adequacy of the recovery process;

Initiation of Physician’s focus to treat the onset of chronic situations or severity of the diseases;

Evaluation of the prognosis and treatment outcomes;

Identification of abnormalities in cardiovascular, cerebrovascular system and overall health assessment;

Blood circulatory status – age of blood vessels based on arterial elasticity, peripheral circulatory status,
organic/functional abnormality of the blood vessels;

Prediction and progression of arteriosclerosis in cases such as Obesity, Hypertension, Hyperlipidemia and
Diabetes;

Useful as a health barometer;
Autonomic testing (including sudomotor testing) is recommended for all patients with type 2 diabetes at the time of
the diagnosis, and 5 years after diagnosis in individual with type 1 diabetes ( Boulton et al., 2005;Tesfaye et al.,
2010;Spallone et al., 2011; Bernardi et al.,2011.)
POLICY - BCBS
Autonomic nervous system (ANS) testing, including parasympathetic function (cardiovagal innervation), sympathetic
adrenergic function (vasomotor adrenergic innervation), and sudomotor function (quantitative sudomotor axon reflex
test [QSART], thermoregulatory sweat test [TST], and silastic sweat imprint test), may be considered medically
necessary for use as a diagnostic tool to evaluate symptoms of vasomotor instability after more common causes have
been excluded by other testing, for any of the following:
1. Diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive
autonomic neuropathy, including:






Diabetic neuropathy
Amyloid neuropathy
Sjogren’s syndrome
Idiopathic neuropathy
Pure autonomic failure
Multiple system dystrophy
2. Evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy;
3. Differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of
consciousness;
4. Evaluate inadequate response to beta blockade in vasodepressor syncope;
5. Evaluate distressing symptoms in the patient with a clinical picture suspicious for distal small fiber neuropathy in
order to diagnose the condition;
6. Differentiate the cause of postural tachycardia syndrome;
7. Evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure;
8. Evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical exam;
9. Diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient;
10. Evaluate and diagnose sympathetically maintained pain, as in reflex sympathetic dystrophy or causalgia; or
11. Evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic failure.
Autonomic nervous system (ANS) testing is considered investigational for all other indications that do not meet the
above criteria, including but not limited to:
1. Screening or routine testing of patients without signs or symptoms of autonomic dysfunction, including patients with
diabetes, hepatic or renal disease;
2. Testing for the sole purpose of monitoring disease intensity or treatment efficacy in diabetes, hepatic or renal
disease;
3. Patients with a clearly diagnosed somatic neuropathy, especially demyelinating neuropathies;
4. Patients with uncomplicated vasovagal syncope;
5. General diagnosis of conditions including, but not limited to:

Asthma

Anxiety and/or stress

General wellness

Obesity

Psychological conditions

Post-partum dysfunctions

Sleep apnea

Chronic fatigue syndrome

Fibromyalgia

Allergic Conditions

Hypertension
Policy – Aetna
I.
Aetna considers autonomic testing such as quantitative sudomotor axon reflex test (QSART), silastic sweat
imprint, and thermoregulatory sweat test (TST) medically necessary for use as a diagnostic tool for any of the following
conditions/disorders:
A.
Amyloid neuropathy
B.
Diabetic autonomic neuropathy
C.
Distal small fiber neuropathy
D.
Idiopathic neuropathy
E.
Multiple system atrophy
F.
Postural tachycardia syndrome
G.
Pure autonomic failure
H.
Recurrent, unexplained syncope
I.
Reflex sympathetic dystrophy or causalgia (sympathetically maintained pain)
J.
Sjogren’s syndrome.
Aetna considers autonomic testing experimental and investigational for all other indications (e.g., chronic fatigue
syndrome/myalgic encephalomyelitis, Raynaud phenomenon, and predicting foot ulcers) because its effectiveness for
indications other than the ones listed above has not been established.
II.
Aetna considers sympathetic skin response testing experimental and investigational for any indications because
it has a relatively low sensitivity and uncertain specificity, and the peer-reviewed medical literature does not support its
effectiveness.
III.
Aetna considers the use of quantitative direct and indirect reflex testing (QDIRT) of sudomotor function
experimental and investigational because its clinical value has not been established.
IV.
Aetna considers quantitative pilomotor axon reflex test (QPART) for evaluating pilomotor function experimental
and investigational because its clinical value has not been established.
V.
Aetna considers autonomic testing using automated devices, in which software automatically generates an
interpretation (e.g., ANSAR, Critical Care Assessment), experimental and investigational in the evaluation of gastroesophageal reflux disease, hypertension, irritable bowel syndrome, paradoxical parasympathetic syndrome, and all
other indications because its clinical value has not been established.
VI.
Aetna considers measurement of cardiac baroreflex sensitivity for assessing cognitive function experimental and
investigational because its clinical value for this indication has not been established.
Code
Number
Description
CPT-4
95921
95922
95923
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
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
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
HCPCS
ICD-9 Procedure
ICD-10 Procedure
ICD-9 Diagnosis
ICD-10 Diagnosis
249.60 –
249.61
E08.40 E08.49
Diabetes mellitus due to underlying
condition with neurological
complications
E08.610
Diabetes mellitus due to underlying
condition with diabetic neuropathic
arthropathy
E08.65
Diabetes mellitus due to underlying
condition with hyperglycemia
E09.40 E09.49
Drug or chemical induced diabetes
mellitus with neurological
complications
E09.610
Drug or chemical induced diabetes
mellitus with diabetic neuropathic
arthropathy
E13.40 E13.49
Other specified diabetes mellitus with
neurological complications
E13.610
Other specified diabetes mellitus with
diabetic neuropathic arthropathy
E10.40 E10.49
Type 1 diabetes mellitus with
neurological complications
250.60 –
250.63
Secondary diabetes mellitus with
neurological manifestations range
Diabetes with neurological
manifestations code range
E10.610
Type 1 diabetes mellitus with diabetic
neuropathic arthropathy
E10.65
Type 1 diabetes mellitus with
hyperglycemia
E11.40 E11.49
Type 2 diabetes mellitus with
neurological complications
E11.610
Type 2 diabetes mellitus with diabetic
neuropathic arthropathy
E11.65
Type 2 diabetes mellitus with
hyperglycemia
E13.40 E13.49
Other specified diabetes mellitus with
neurological complications
E13.610
Other specified diabetes mellitus with
diabetic neuropathic arthropathy
277.30 277.39
Amyloidosis
E85.0 E85.9
Amyloidosis
337.00 337.9
Disorders of the autonomic nervous
system code range
G90.1 G90.9
Disorders of the autonomic nervous
system
356.0 356.9
Hereditary and idiopathic peripheral
neuropathy code range
G60.0 G60.9
Hereditary and idiopathic neuropathy
357.2
Polyneuropathy in diabetes
E08.40,
E08.42,
E09.40,
E09.42,
E10.40,
E10.42,
E11.40,
E11.42,
E13.40,
E13.42
See code descriptions above
357.4
Polyneuropathy in other diseases
classified elsewhere
G63
Polyneuropathy in diseases classified
elsewhere
357.81
Chronic inflammatory demyelinating
polyneuritis
G61.81
Chronic inflammatory demyelinating
polyneuritis
427.89
Other specified cardiac dysrhythmias
I49.8
Other specified cardiac arrhythmias
710.2
Sicca syndrome
M35.00 M35.09
Sicca syndrome
780.2
Syncope and collapse
R55
Syncope and collapse
785.0
Tachycardia, unspecified
R00.0
Tachycardia, unspecified
ICD-10 codes covered if selection criteria are met:
E08.42
E09.42
Polyneuropathy in diabetes
E10.40 - E10.49
E11.40 - E11.49
E13.40 - E13.49
Diabetes with neurological manifestations
E85.0 - E85.9
Amyloidosis
G60.3
Idiopathic progressive neuropathy
G60.8
Other hereditary and idiopathic neuropathies
G60.9
Hereditary and idiopathic neuropathy, unspecified
G63
Polyneuropathy in diseases classified elsewhere
G90.50 - G90.59
Complex regional pain syndrome l (CRPS l)
G90.9
Disorder of the autonomic nervous system, unspecified [postural tachycardia syndrome] [not
covered for paradoxical parasympathetic syndrome]
M35.00 - M35.09
Sicca syndrome [Sjegren]
R00.0
Tachycardia, unspecified [postural tachycardia syndrome]
R55
Syncope and collapse
ICD-10 codes not covered for indications listed in the CPB::
G04.90
Encephalitis and encephalomyelitis, unspecified
I10
Essential (primary) hypertension
I73.00 - I73.01
Raynaud's syndrome
K21.9
Gastro-esophageal reflux disease without esophagitis
K58.0 - K58.9
Irritable bowel syndrome
R53.82
Chronic fatigue, unspecified