Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices

Policy #:07.02.09e

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

AMBULATORY BLOOD PRESSURE MONITORING

MEDICALLY NECESSARY
Ambulatory blood pressure monitoring (ABPM) for a 24 hour period or longer is considered medically necessary and, therefore, covered for any of the following indications when there is an absence of hypertensive end-organ damage on physical examination and appropriate laboratory testing:
  • Suspected white coat hypertension demonstrated by the following:
    • The individual has persistently raised blood pressure greater than 140/90 mmHg on at least three clinic/office visits, with two separate measurements made at each visit, and blood pressure less than 140/90 mmHg documented on at least two separate blood pressure measurements taken outside the office.
  • Suspected episodic hypertension (e.g., pheochromocytoma that may precipitate hypertension)
  • Hypertension that is resistant or refractory to medications
  • Hypotensive symptoms thought to be related to taking antihypertensive medications
  • Autonomic dysfunction (e.g., sympathetic autonomic nervous system)
  • Suspected masked hypertension (i.e., office blood pressure is normal, but blood pressure during regular activities is elevated)
    • There is a documented clinical suspicion of hypertension (e.g., individuals with left ventricular hypertrophy) but normal or prehypertensive causal measurements
  • In accordance with the American Heart Association, for children and adolescents, monitoring blood pressure patterns in chronic diseases associated with hypertension (e.g., chronic kidney disease, diabetes)

NOT MEDICALLY NECESSARY
All other uses for ABPM are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis of illness or injury.

HOME BLOOD PRESSURE MONITORING DEVICES

Home blood pressure monitoring (HBPM) devices are benefit contract exclusions except for the following conditions:
  • End-stage renal disease in individuals who are receiving home dialysis
  • Pregnancy-induced hypertension
  • Hypertension complicated by pregnancy
  • As required based on Affordable Care Act (ACA) preventive mandates

All other uses for HBPM devices are benefit contract exclusions and, therefore, not eligible for reimbursement consideration.

Individual member benefits must be verified.

AMBULATORY BLOOD PRESSURE MONITORING AND HOME BLOOD PRESSURE MONITORING DEVICES FOR SCREENING

For medical necessity criteria on ABPM or HBPM devices as a screening service, refer to medical policy 00.06.02 Preventive Care Services

REPLACEMENT OF HOME BLOOD PRESSURE MONITORING DEVICES

The Company may determine the reasonable useful lifetime of a specific HBPM device based on the manufacturer's recommendation.

In the absence of manufacturer's recommendations, the Company may determine the reasonable useful lifetime of a HBPM device, but is generally not less than five years. Replacement of one or more of its components (parts) that are necessary for its proper functioning due to misuse, abuse, or failure to adequately maintain or care for the item is excluded from coverage.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

In the circumstance that ambulatory blood pressure monitoring (ABPM) needs to be performed more than once on an individual, the qualifying criteria as described in the policy must be met for each subsequent ABPM test.

ABPM IN CHILDREN AND ADOLESCENTS

Conducting ABPM requires specific equipment (that has been validated according to Association for the Advancement of Medical Instrumentation). Ambulatory blood pressure monitoring in children and adolescents should be used by experts in the field of pediatric hypertension who are experienced in its use and interpretation based on gender-, age-, and height-specific ABPM normative data.

American Heart Association Classification of Ambulatory Blood Pressure Levels in Children (2014)
ClassificationClinic Blood PressureMean Ambulatory Systolic Blood PressureSystolic or Diastolic Blood Pressure Load
Normal BP<90th percentile<95th percentile<25%
White Coat Hypertension>95th percentile<95th percentile<25%
Masked Hypertension<95th percentile>95th percentile>25
Pre-Hypertension>90th percentile or >120/80 mm Hg<95th percentile>25%
Ambulatory Hypertension>95th percentile>95th percentile25%-50%
Severe Ambulatory Hypertension>95th percentile>95th percentile>50%

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, ABPM is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Subject to the terms and conditions of the applicable benefit contract, home blood pressure monitoring (HBPM) devices are covered under the medical benefits of the Company's products.

US FOOD AND DRUG ADMINISTRATION (FDA)

The FDA has approved several ambulatory blood pressure monitoring units and considers these devices to be Class II devices, which are exempt from premarket notification procedures.

Description

AMBULATORY BLOOD PRESSURE MONITORING (24-HOUR SPHYGMOMANOMETER)

Ambulatory blood pressure monitoring (ABPM) involves the use of a noninvasive device that measures blood pressure in 24-hour cycles (24 hour sphygmomanometer). The device consists of a portable sphygmomanometer attached to a recording device. The ABPM device is fitted to and removed from the individual by a trained technician. The sphygmomanometer inflates at predetermined times, generally every 30 minutes, and the blood pressure recorded at each inflation is stored. The individual performs normal activities while wearing the monitor. The device provides information about blood pressure during daily activities, as well as during sleep.

Automated ABPM is considered more accurate than individual self-monitoring. Therefore, it is generally thought that readings obtained at frequent intervals throughout the day and night would help the professional provider better manage the individual's care. These stored, 24-hour measurements are later interpreted at the professional provider’s office. A clinician is required to interpret the collected data by uploading it onto a computer where device specific programs are used to categorize and analyze the measurements.

The information that ABPM provides, for example, can help a professional provider determine whether an individual is truly hypertensive or is exhibiting white coat hypertension (WCH). WCH is a condition characterized by persistently raised blood pressure in the doctor's office with a normal ambulatory blood pressure. WCH is defined as blood pressure greater than 140/90 mmHg on at least three clinic/office visits, with two separate measurements made at each visit, and blood pressure less than 140/90 mmHg documented on at least two separate blood pressure measurements taken outside the office.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) noted that, in addition to assisting with the evaluation of white coat hypertension, ABPM is also helpful with the assessment of apparent antihypertensive drug resistance, hypotensive symptoms while on antihypertensive medications, episodic hypertension, autonomic dysfunction, and masked hypertension.

The American Heart Association states ABPM is a useful tool in evaluating blood pressure in children and adolescents for similar indications as in adults, including use in children and adolescents with elevated office blood pressure to distinguish true hypertension from WCH. ABPM levels for children and adolescents should be interpreted using appropriate pediatric normative values, which use gender- and height-specific values derived from large pediatric populations. According to the American Academy of Pediatrics, conducting ABPM requires specific equipment and trained staff. Therefore, ABPM in children and adolescents should be performed by experts in the field of pediatric hypertension who are experienced in its use and interpretation.

HOME BLOOD PRESSURE MONITORING DEVICES

The two main types of home blood pressure monitoring (HBPM) devices are non-automatic and automatic (or electronic). Many of these devices are available for retail purchase, and some have undergone technical validation according to recommended protocols.

SCREENING SERVICES FOR HIGH BLOOD PRESSURE

The US Preventive Services Task Force (USPSTF) (2015), has issued a recommendation for screening for high blood pressure.
References


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Company Benefit Contracts.

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Hansen TW, Jeppesen J, Rasmussen S, et al. Ambulatory blood pressure and mortality: a population-based study. Hypertension. 2005;45(4):499-504.

Head GA, Mihailidou AS, Duggan KA, et al. Definition of ambulatory blood pressure targets for diagnosis and treatment of hypertension in relation to clinic blood pressure: prospective cohort study. BMJ. 2010;340:c1104.

Hemmelgarn BR, McAllister FA, Myers MG, et al. The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1- blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol. 2005;21(8):645-56.

Hermida RC, Calvo C, Ayala DE, et al. Treatment of non-dipper hypertension with bedtime administration of valsartan. J Hypertens. 2005;23(10):1913-22.

Ingelsson E, Björklund-Bodegård K, Lind L, et al. Diurnal blood pressure pattern and risk of congestive heart failure. JAMA. 2006;295(24):2859-66.

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Kario K. Time for focus on morning hypertension: pitfall of current antihypertensive medication. Am J Hypertens. 2005;18(2 Pt 1):149-51.

Kario K, Pickering TG, Umeda Y, et al. Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation. 2003;107(10):1401-6.

Krakoff LR. Cost-effectiveness of ambulatory blood pressure: a reanalysis. Hypertension. 2006;47(1):29-34.

Li Y, Thijs L, Hansen TW, et al. Prognostic value of the morning blood pressure surge in 5645 subjects from 8 populations. Hypertension. 2010;55(4):1040-8.

Lurbe E, Redon J, Kesani A, et al. Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med. 2002;347(11):797-805.

Mallion JM, Clerson P, Bobrie G, et al. Predictive factors for masked hypertension within a population of controlled hypertensives. J Hypertens. 2006;24(12):2365-70.

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Coding

Inclusion of a code in this table does not imply reimbursement. 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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

93784, 93786, 93788, 93790


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

AMBULATORY BLOOD PRESSURE MONITORING (93784, 93786, 93788, 93790)

G90.8 Other disorders of autonomic nervous system

G90.9 Disorder of the autonomic nervous system, unspecified

I10 Essential (primary) hypertension

I15.0 Renovascular hypertension

I15.1 Hypertension secondary to other renal disorders

I15.2 Hypertension secondary to endocrine disorders

I15.8 Other secondary hypertension

I15.9 Secondary hypertension, unspecified

R03.0 Elevated blood-pressure reading, without diagnosis of hypertension


HOME BLOOD PRESSURE MONITORING DEVICES (A4460, A4463, A4670)

I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

N18.6 End stage renal disease

O10.011 Pre-existing essential hypertension complicating pregnancy, first trimester

O10.012 Pre-existing essential hypertension complicating pregnancy, second trimester

O10.013 Pre-existing essential hypertension complicating pregnancy, third trimester

O10.019 Pre-existing essential hypertension complicating pregnancy, unspecified trimester

O10.02 Pre-existing essential hypertension complicating childbirth

O10.03 Pre-existing essential hypertension complicating the puerperium

O10.111 Pre-existing hypertensive heart disease complicating pregnancy, first trimester

O10.112 Pre-existing hypertensive heart disease complicating pregnancy, second trimester

O10.113 Pre-existing hypertensive heart disease complicating pregnancy, third trimester

O10.119 Pre-existing hypertensive heart disease complicating pregnancy, unspecified trimester

O10.12 Pre-existing hypertensive heart disease complicating childbirth

O10.13 Pre-existing hypertensive heart disease complicating the puerperium

O10.211 Pre-existing hypertensive chronic kidney disease complicating pregnancy, first trimester

O10.212 Pre-existing hypertensive chronic kidney disease complicating pregnancy, second trimester

O10.213 Pre-existing hypertensive chronic kidney disease complicating pregnancy, third trimester

O10.219 Pre-existing hypertensive chronic kidney disease complicating pregnancy, unspecified trimester

O10.22 Pre-existing hypertensive chronic kidney disease complicating childbirth

O10.23 Pre-existing hypertensive chronic kidney disease complicating the puerperium

O10.311 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimester

O10.312 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester

O10.313 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimester

O10.319 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, unspecified trimester

O10.32 Pre-existing hypertensive heart and chronic kidney disease complicating childbirth

O10.33 Pre-existing hypertensive heart and chronic kidney disease complicating the puerperium

O10.411 Pre-existing secondary hypertension complicating pregnancy, first trimester

O10.412 Pre-existing secondary hypertension complicating pregnancy, second trimester

O10.413 Pre-existing secondary hypertension complicating pregnancy, third trimester

O10.419 Pre-existing secondary hypertension complicating pregnancy, unspecified trimester

O10.42 Pre-existing secondary hypertension complicating childbirth

O10.43 Pre-existing secondary hypertension complicating the puerperium

O10.911 Unspecified pre-existing hypertension complicating pregnancy, first trimester

O10.912 Unspecified pre-existing hypertension complicating pregnancy, second trimester

O10.913 Unspecified pre-existing hypertension complicating pregnancy, third trimester

O10.919 Unspecified pre-existing hypertension complicating pregnancy, unspecified trimester

O10.92 Unspecified pre-existing hypertension complicating childbirth

O10.93 Unspecified pre-existing hypertension complicating the puerperium

O11.1 Pre-existing hypertension with pre-eclampsia, first trimester

O11.2 Pre-existing hypertension with pre-eclampsia, second trimester

O11.3 Pre-existing hypertension with pre-eclampsia, third trimester

O11.4 Pre-existing hypertension with pre-eclampsia, complicating childbirth

O11.5 Pre-existing hypertension with pre-eclampsia, complicating the puerperium

O11.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester

O13.1 Gestational [pregnancy-induced] hypertension without significant proteinuria, first trimester

O13.2 Gestational [pregnancy-induced] hypertension without significant proteinuria, second trimester

O13.3 Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester

O13.4 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating childbirth

O13.5 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating the puerperium

O13.9 Gestational [pregnancy-induced] hypertension without significant proteinuria, unspecified trimester

O14.00 Mild to moderate pre-eclampsia, unspecified trimester

O14.02 Mild to moderate pre-eclampsia, second trimester

O14.03 Mild to moderate pre-eclampsia, third trimester

O14.04 Mild to moderate pre-eclampsia, complicating childbirth

O14.05 Mild to moderate pre-eclampsia, complicating the puerperium

O14.10 Severe pre-eclampsia, unspecified trimester

O14.12 Severe pre-eclampsia, second trimester

O14.13 Severe pre-eclampsia, third trimester

O14.14 Severe pre-eclampsia complicating childbirth

O14.15 Severe pre-eclampsia, complicating the puerperium

O14.90 Unspecified pre-eclampsia, unspecified trimester

O14.92 Unspecified pre-eclampsia, second trimester

O14.93 Unspecified pre-eclampsia, third trimester

O14.94 Unspecified pre-eclampsia, complicating childbirth

O14.95 Unspecified pre-eclampsia, complicating the puerperium

O16.1 Unspecified maternal hypertension, first trimester

O16.2 Unspecified maternal hypertension, second trimester

O16.3 Unspecified maternal hypertension, third trimester

O16.4 Unspecified maternal hypertension, complicating childbirth

O16.5 Unspecified maternal hypertension, complicating the puerperium

O16.9 Unspecified maternal hypertension, unspecified trimester

R03.0 Elevated blood-pressure reading, without diagnosis of hypertension

Z99.2 Dependence on renal dialysis




HCPCS Level II Code Number(s)


A4660 Sphygmomanometer/blood pressure apparatus with cuff and stethoscope

A4663 Blood pressure cuff only

A4670 Automatic blood pressure monitor



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 07.02.09e:
06/06/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 10/01/2016
Version Issued Date: 09/30/2016
Version Reissued Date: 06/06/2018

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© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.