Autonomic Testing denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic tests. The current medical guidelines do not recommend autonomic testing for the evaluation of patients with dysautonomia suggestive of postural orthostatic tachycardia syndrome (POTS). According to one medical study, “Elements of the autonomic examination include variations in the pulse, postural measurements of blood pressure and heart rate, pupillary light reactions, skin coloration and temperature, patterns of sweating, and other organ-specific physical findings relevant to the individual patient's presentation.” The records available for review indicate that this patient has a history of dizziness and dysautonomia consistent with POTS. The provider recommended evaluation of the patient with autonomic testing to confirm the patient’s diagnosis and to guide a future course of treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the nerve testing (autonomic testing) performed for evaluation of the enrollee’s small fiber neuropathy symptoms. Findings: The 3 physician reviewers found that in this case, the patient was under evaluation for multiple symptoms that suggested neuropathy. Small fiber neuropathy can be difficult to diagnose as clinical testing and EMG may be normal. Skin biopsy for small fibers may be helpful, but many patients have other associated symptoms that may indicate involvement of small autonomic fibers which may associated with acroparesthesias (tingling in the hands and feet), abnormal tearing, gastroparesis, constipation, orthostatic hypotension, loss of cardiac beat to best variability, and abnormal pupillary responses.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic tests. The current medical guidelines do not recommend autonomic testing for the evaluation of patients with dysautonomia suggestive of postural orthostatic tachycardia syndrome (POTS). According to one medical study, “Elements of the autonomic examination include variations in the pulse, postural measurements of blood pressure and heart rate, pupillary light reactions, skin coloration and temperature, patterns of sweating, and other organ-specific physical findings relevant to the individual patient's presentation.” The records available for review indicate that this patient has a history of dizziness and dysautonomia consistent with POTS. The provider recommended evaluation of the patient with autonomic testing to confirm the patient’s diagnosis and to guide a future course of treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic testing.Findings: Two physician reviewers found that a study notes autonomic testing may be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP).

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Autonomic Testing, then check the rights and deadlines that apply to your plan.