Medical Policies Online - Policy #: 05.00.16c

Claim Payment Policy

Title:

Blood Pressure Devices for Home Use

Policy #:

05.00.16c

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company coverage and reimbursement position for blood pressure devices for home use.

For information on other policies related to this topic, refer to the Cross References Table in this policy.

Description

The two main types of blood pressure devices for home use are non-automated and automated (or electronic).

Non-automated blood pressure devices are either aneroid or digital. An aneroid device has a dial gauge, a manually inflatable cuff, and a built-in stethoscope. A digital device has a gauge, a manually inflatable cuff, a built-in stethoscope, and a screen that displays the blood pressure measurement.

An automated blood pressure device is equipped with a pressure sensor, a digital display screen, and an upper arm cuff. An electrically driven pump raises the pressure in the cuff. After the device is activated, the cuff automatically inflates and deflates, and the individual's blood pressure measurement appears on the screen.

Policy

Blood pressure devices for home use are benefit contract exclusions except for the following conditions:

End-stage renal disease in individuals who are receiving home dialysis
Pregnancy-induced hypertension or hypertension complicated by pregnancy

All other indications are benefit contract exclusions and, therefore, not covered.

Individual member benefits must be verified.

Guidelines

MEDICARE

Although original Medicare only covers blood pressure devices in the home setting for individuals with end-stage renal disease, Medicare Advantage members are covered in accordance with this policy.

References

Company Benefit Contracts.

TriCenturion. Local Coverage Determination (LCD). L11498: Home dialysis supplies and equipment. [TriCenturion Web site]. Original: 10/01/93. (Revised: 01/01/07). Available at: http://www.tricenturion.com/content/Doc_View.cfm?type=LCDCurr&File=lcd%20for%20home%20dialysis%20supplies%20and%20equipment%2Ehtm. Accessed April 4, 2007.

Coding Table

Inclusion of a code in this table does not imply reimbursement coverage. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	N/A
ICD Procedure	N/A
ICD Diagnosis	403.11: Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease 403.91: Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease 404.12: Hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney disease stage V or end stage renal disease 404.13: Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease stage V or end stage renal disease 404.92: Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage V or end stage renal disease 404.93: Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease 585.6: End-stage renal disease 642.00: Benign essential hypertension, complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care 642.01: Benign essential hypertension with delivery 642.02: Benign essential hypertension, with delivery, with current postpartum complication 642.03: Benign essential hypertension, antepartum 642.04: Benign essential hypertension, previous postpartum complication 642.10: Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care 642.11: Hypertension secondary to renal disease, with delivery 642.12: Hypertension secondary to renal disease, with delivery, with current postpartum complication 642.13: Hypertension secondary to renal disease, antepartum 642.14: Hypertension secondary to renal disease, previous postpartum condition 642.20: Other preexisting hypertension complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care 642.21: Other preexisting hypertension, with delivery 642.22: Other preexisting hypertension, with delivery, with current postpartum complication 642.23: Other preexisting hypertension, antepartum 642.24: Other preexisting hypertension, previous postpartum condition 642.30: Transient hypertension of pregnancy, unspecified as to episode of care 642.31: Transient hypertension of pregnancy, with delivery 642.32: Transient hypertension of pregnancy, with delivery, with current postpartum complication 642.33: Transient hypertension of pregnancy, antepartum 642.34: Transient hypertension of pregnancy, previous postpartum condition 642.40: Mild or unspecified preeclampsia, unspecified as to episode of care 642.41: Mild or unspecified preeclampsia, with delivery 642.42: Mild or unspecified preeclampsia, with delivery, with current postpartum complication 642.43: Mild or unspecified preeclampsia, antepartum 642.44: Mild or unspecified preeclampsia, previous postpartum condition 642.50: Severe preeclampsia, unspecified as to episode of care 642.51: Severe preeclampsia, with delivery 642.52: Severe preeclampsia, with delivery, with current postpartum complication 642.53: Severe preeclampsia, antepartum 642.54: Severe preeclampsia, previous postpartum condition 642.70: Preeclampsia or eclampsia superimposed on preexisting hypertension, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care 642.71: Preeclampsia or eclampsia superimposed on preexisting hypertension, with delivery 642.72: Preeclampsia or eclampsia superimposed on preexisting hypertension, with delivery with current postpartum complication 642.73: Preeclampsia or eclampsia superimposed on preexisting hypertension, antepartum 642.74: Preeclampsia or eclampsia superimposed on preexisting hypertension, postpartum 642.90: Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care 642.91: Unspecified hypertension, with delivery 642.92: Unspecified hypertension, with delivery, with current postpartum complication 642.93: Unspecified hypertension, antepartum 642.94: Unspecified hypertension, previous postpartum condition
HCPCS Level II	A4660: Sphygmomanometer/blood pressure apparatus with cuff and stethoscope A4663: Blood pressure cuff only A4670: Automatic blood pressure monitor

Revenue Codes	N/A

Cross References

Cross Reference Policies

05.00.44f:

Repair and Replacement of Durable Medical Equipment (DME)

07.02.09:Ambulatory Blood Pressure Monitoring (ABPM)

Version Effective Date: 06/05/2007