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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