Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic nervous system function testing (sudomotor testing and combined parasympathetic and sympathetic adrenergic function testing). The autonomic nervous system is responsible for various elements functions including heart rate, body temperature, breathing, digestion, and sensation. The autonomic nervous system is composed of the sympathetic and parasympathetic nervous systems and their interplay. Disease occurs when there is the parasympathetic and sympathetic are unbalanced or when there is direct damage to the autonomic nervous system in various disease states. Some of the symptoms that can be linked to autonomic nervous system disease are dizziness, sweating abnormalities, and loss of appetite, dry mouth, lightheadedness. The autonomic system can be evaluated using several tests including tilt table test, monitor of heart rate and blood pressure during specific situations, gastric emptying studies, quantitative sudomotor, axon reflex test, thermoregulatory sweat test, adrenergic testing, and urodynamics. The records provided for review document that this patient has a history of complaints that raise concern for a possible autonomic issue. The patient has reported symptoms including diminished libido, lightheaded, abnormalities in blood pressure. Additionally, the patient has an autoimmune history of Sjogrens. In some instances, autoimmune dysfunction can be related to autonomic dysfunction. The examinations performed to evaluate dysfunction in the autonomic nervous system are well established forms of testing that help identify and localize autonomic dysfunction accurately. Information from such testing can lead to appropriate diagnosis and subsequently altering treatment planning. For these reasons, the autonomic nervous system function testing (sudomotor testing and combined parasympathetic and sympathetic adrenergic function testing) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the autonomic nervous system function testing (sudomotor testing and combined parasympathetic and sympathetic adrenergic function testing) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 2 is board certified in neurology and is actively practicing. Physician reviewer 3 is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.