Corporate Medical Policy Ambulatory Blood Pressure Monitoring

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1 Corporate Medical Policy Ambulatory Blood Pressure Monitoring File Name: Origination: Last CAP Review: Next CAP Review: Last Review: ambulatory_blood_pressure_monitoring 7/1982 4/2016 4/2017 4/2016 Description of Procedure or Service Ambulatory blood pressure monitors (24-hour sphygmomanometers) are portable devices that record blood pressure repeatedly while the patient is involved in daily activities. There are various types of ambulatory monitors; this policy addresses fully automated monitors, which inflate and record blood pressure at pre-programmed intervals. Ambulatory blood pressure monitoring (ABPM), typically done over a 24-hour period with a fully automated monitor, provides more detailed blood pressure information than typically obtained during office visits. The greater number of readings with ABPM ameliorates the variability of single blood pressure measurements, and is more representative of the circadian rhythm of blood pressure compared to the limited number obtained during office measurement. There are a number of potential applications of ABPM. One of the most common is evaluating suspected white-coat hypertension (WCH), which is defined as an elevated office blood pressure with normal blood pressure readings outside the physician s office. The etiology of WCH is poorly understood but may be related to an alerting" or anxiety reaction associated with visiting the physician's office. In evaluating patients having elevated office blood pressure, ABPM is often intended to identify patients with normal ambulatory readings who do not have sustained hypertension. Since this group of patients would otherwise be treated based on office blood pressure readings alone, ABPM could improve outcomes by allowing these patients to avoid unnecessary treatment. However, this assumes patients with WCH are not at increased risk for cardiovascular events and would not benefit from antihypertensive treatment. This policy does not directly address other uses of ABPM, including the use of ABPM for the evaluation of masked hypertension. Masked hypertension refers to normal BP readings in the office and elevated BP readings outside of the office. This phenomenon has recently received greater attention, with estimates that up to 10-20% of individuals may exhibit this pattern. Many ambulatory blood pressure monitors have received clearance to market through the U.S. Food and Drug Administration (FDA) 510(k) marketing clearance process. As an example of an FDA indication for use, the Welch Allyn ABPM 6100 is indicated as an aid or adjunct to diagnosis and treatment when it is necessary to measure adult or pediatric patients systolic and diastolic blood pressures over an extended period of time. The system is only for measurement, recording, and display. It makes no diagnosis. ***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician. Policy Page 1 of 6

2 BCBSNC will provide coverage for Ambulatory Blood Pressure Monitoring when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. Benefits Application This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. When Ambulatory Blood Pressure Monitoring is covered Automated ambulatory blood pressure monitoring over a 24-hour period may be considered medically necessary: To differentiate between white coat hypertension or other symptoms/findings inconsistent with in office blood pressure readings and true hypertension; or To monitor for suspected Episodic Hypertension (e.g. Pheochromocytoma); or To monitor for hypertension resistant to increasing medications; or To monitor for hypotensive symptoms while taking antihypertensive medications; or To monitor for autonomic dysfunction; or To evaluate whether antihypertensive therapy is moderating the early morning blood pressure surge. When Ambulatory Blood Pressure Monitoring it is not covered Ambulatory Blood Pressure Monitoring is considered not medically necessary when the medical criteria listed above are not met. Ambulatory blood pressure monitoring in patients who have not tried conventional intermittent home blood pressure monitoring is considered not medically necessary. Ambulatory blood pressure monitoring for patients with elevated office BP is considered not medically necessary, including but not limited to repeat testing in patients with persistently elevated office BP. Ambulatory blood pressure monitoring to screen for hypertension is considered not medically necessary. Policy Guidelines Ambulatory blood pressure monitoring (ABPM) performed over a 24-hour period is a more accurate method for evaluating blood pressure (BP) compared with office measurements and home BP measurements. Reference values for normal and abnormal ABPM results have been derived from epidemiologic research for both adults and children. These reference values vary slightly among different sources but are available for clinical use. Data from large prospective cohort studies establish that ABPM correlates more strongly with cardiovascular outcomes compared with other methods of BP measurement. Prospective cohort studies also indicate that white coat hypertension (WCH), as defined by ABPM, is associated with an intermediate risk of cardiovascular outcomes compared with normotensive and hypertensive patients. Studies comparing home BP monitoring and office monitoring to ABPM as the criterion standard report that the sensitivity and specificity of alternative methods of diagnosing hypertension are suboptimal. This is true for both adult and pediatric patients. Substantial percentages of patients Page 2 of 6

3 with elevated office BP are found to have normal BP on ABPM, and these patients are at risk for over diagnosis and overtreatment based on office BP measurements alone. Use of ABPM in these patients will improve outcomes by eliminating the inconvenience and morbidity of pharmacologic treatment in patients who are not expected to benefit. Billing/Coding/Physician Documentation Information This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at They are listed in the Category Search on the Medical Policy search page. Applicable codes: 93784, 93786, 93788, BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. Scientific Background and Reference Sources BCBSA Medical Policy Reference Manual - 12/95 Medical Policy Advisory Group - 1/99 Specialty Matched Consultant Advisory Panel - 8/2000 Medical Policy Advisory Group - 10/2000 Specialty Matched Consultant Advisory Panel - 8/2002 BCBSA Medical Policy Reference Manual [Electronic Version] , 10/08/02 Specialty Matched Consultant Advisory Panel - 6/2004 Canadian Coordinating Office for Health Technology Assessment (CCOHTA). (2003, January) 24-hour ambulatory blood pressure monitoring. Retrieved November 15, 2005, from California Technology Assessment Forum. (2004, October 20) Utility of ambulatory blood pressure monitoring. Retrieved November 15, 2005, from BCBSA Medical Policy Reference Manual [Electronic Version] , 5/23/05 Appel L, Robinson K, Guallar E. Utility of Blood Pressure Monitoring Outside of the Clinic Setting. Evidence Report/Technology Assessment No. 63 (Prepared by the Johns Hopkins Evidence-based Practice Center under Contract No ). AHRQ Publication No. 03-E004. Rockville, MD: Agency for Healthcare Research and Quality. November Retrieved October 12, 2007 from downloads/pub/evidence/pdf/utbp/utbp.pdf BCBSA Medical Policy Reference Manual [Electronic Version] , 4/17/07 BCBSA Medical Policy Reference Manual [Electronic Version] , 7/10/08 Specialty Matched Consultant Advisory Panel 3/2010 Page 3 of 6

4 Specialty Matched Consultant Advisory Panel review 4/2011 BCBSA Medical Policy Reference Manual [Electronic Version] , 12/8/11 Medical Director review 3/2012 Specialty Matched Consultant Advisory Panel review 10/2012 BCBSA Medical Policy Reference Manual [Electronic Version] , 12/10/12 Specialty Matched Consultant Advisory Panel review 4/2013 O'Brien E, Asmar R, Beilin L, Imai Y, Mancia G, Mengden T, Myers M, Padfield P, Palatini P, Parati G, Pickering T, Redon J, Staessen J, Stergiou G, Verdecchia P, European Society of Hypertension Working Group on Blood Pressure Monitoring. Practice guidelines of the European Society of Hypertension for clinic, ambulatory and self blood pressure measurement. J Hypertens Apr;23(4): Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ, National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA May 21;289(19): Retrieved from Quinn RR, Hemmelgarn BR, Padwal RS, et al., Canadian Hypertension Education Program. The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1- blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol May;26(5): Retrieved from Urbina E, Alpert B, Flynn J et al. Ambulatory blood pressure monitoring in children and adolescents: recommendations for standard assessment: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the council on cardiovascular disease in the young and the council for high blood pressure research. Hypertension 2008; 52(3): BCBSA Medical Policy Reference Manual [Electronic Version] , 1/9/14 Campbell NR1, Hemmelgarn BR. New recommendations for the use of ambulatory blood pressure monitoring in the diagnosis of hypertension. CMAJ Apr 3;184(6): National Institute of Clinical Excellence (NICE) Hypertension: Clinical Management of Primary Hypertension in Adults. August Specialty Matched Consultant Advisory Panel review 4/2014 Medical Director review 4/2014 BCBSA Medical Policy Reference Manual [Electronic Version] , 1/15/15 Specialty Matched Consultant Advisory Panel review 4/2015 Medical Director review 5/2015 Specialty Matched Consultant Advisory Panel review 4/2016 Page 4 of 6

5 Medical Director review 4/2016 Policy Implementation/Update Information 7/82 Original policy: Experimental/Investigative 11/84 Reaffirmed 4/86 Evaluated: Investigational 3/88 Evaluated: Investigational 12/95 Evaluated: Reaffirmed 1/99 Reaffirmed: Medical Policy Advisory Group 8/00 Specialty Matched Consultant Advisory Panel. Changed from investigational to not medically necessary. 9/00 System coding changes. 10/00 Medical Policy Advisory Group review. No changes to policy. Approve. 11/01 Coding Format Change. 11/01 Revised coding format change. 9/02 Specialty Matched Consultant Advisory Panel review. Duplicate codes removed from the Billing and Coding Section. Added, "There are no controlled studies to demonstrate the value of ambulatory blood pressure monitoring over home blood pressure monitoring in terms of clinical management or outcomes." to Policy Guideline section. 12/03 Benefits Application and Billing/Coding sections updated for consistency. 7/29/04 Specialty Matched Consultant Advisory Panel review 6/28/2004 with no changes made to policy criteria. References added. 3/16/06 Specialty Matched Consultant Advisory Panel review 2/27/06. No changes made to policy criteria. Rationale added to Policy Guidelines section. Policy number added to Key Words. References updated. 4/7/08 References updated. Specialty Matched Consultant Advisory Panel review 3/12/08. No change in policy statement. (adn) 4/27/10 Description section revised. Specialty Matched Consultant Advisory Panel review 3/24/10. Removed Medical Policy number. No changes in policy statement. (mco) 7/6/10 Medical Policy changed to Evidenced Based Guideline.(mco) 5/10/11 Specialty Matched Consultant Advisory Panel review 4/2011. No change in guideline statement. (mco) 3/20/12 Description section updated. When Recommended section revised to state: Automated ambulatory blood pressure monitoring over a 24-hour period is recommended for patients Page 5 of 6

6 with elevated office BP, when performed one time to differentiate between white coat hypertension and true hypertension, and when the following conditions are met: Office blood pressure elevation is in the mild to moderate range (<180/110), not requiring immediate treatment with medications; There is an absence of hypertensive end-organ damage on physical examination and laboratory testing. When not Recommended section revised to state: Other than listed above, uses of ambulatory blood pressure monitoring for patients with elevated office BP, including but not limited to repeated testing in patients with persistently elevated office BP, is not recommended. References updated. Medical Director review 3/2012. (mco) 1/29/13 Specialty Matched Consultant Advisory Panel review 10/2012. References updated. Medical Director review 1/2013. (mco) 5/14/13 Specialty Matched Consultant Advisory Panel review 4/2013. References updated. Medical Director review 3/2013. The following statement added to the Not Recommended section: Use of ambulatory blood pressure monitoring is not recommended in patients who have not tried conventional intermittent home blood pressure monitoring to evaluate for the above conditions. The When Recommended section updated as follows: Automated ambulatory blood pressure monitoring over a 24-hour period is recommended: To differentiate between white coat hypertension and true hypertension; To rule out suspected Episodic Hypertension (e.g. Pheochromocytoma); To monitor for hypertension resistant to increasing medications; To monitor for hypotensive symptoms while taking antihypertensive medications; To monitor for autonomic dysfunction; To evaluate whether antihypertensive therapy is moderating the early morning Blood pressure surge. (mco) 2/25/14 References updated. No changes to guideline statements. (mco) 5/13/14 Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. References updated. No changes to Guideline Statements. (mco) 7/1/15 Specialty Matched Consultant Advisory Panel review 4/2015. Medical Director review 5/2015. Evidence Based Guideline converted to Corporate Medical Policy. When Covered section updated to include, or other symptoms or findings inconsistent with in office blood pressure readings. When Covered section revised. Notification given 7/1/15 for effective date of 9/1/15. (td) 5/31/16 Specialty Matched Consultant Advisory Panel review 4/27/2016. Medical Director review 4/2016. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review and revise its medical policies periodically. Page 6 of 6

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