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Medical Policy Bulletin

Remote Patient Monitoring
MA12.010b

Policy

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.​


Remote patient monitoring (RPM) services in the home setting (i.e., where the individual resides) may be eligible for separate reimbursement consideration by the Company for individuals receiving active treatment for acute decompensated heart failure (defined as heart failure with the initiation of and/or medication adjustment) when the provider submits and receives approval from the Company for their RPM program as indicated below.


All RPM program submissions must be sent to UMprogramsubmission@ibx.com for review and approval. The following information should be included with the program submission: 
  • Program description         
  • Billing provider information 
  • Billing provider number ​
  • National Provider Identification Number
RPM SUBMISSION REQUIREMENTS 

The RPM program description must include documentation of all the following components: 
  • Clinical parameters to be monitored include, but are not limited to, weight, blood pressure, respiration rate, and pulse oximetry
  • How the reliable and valid data will be digitally sent to the distant provider with the goal to develop and manage a treatment plan while an individual returns to the baseline for their condition, or establishes a new baseline 
  • How the data will be transmitted to the provider at a frequency that allows the provider to react to changes in data in a reasonable amount of time. 
  • Identification of the specific monitoring medical device as defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act, through a secure, HIPAA-compliant platform
  • How the technical support services will be provided to the individuals for the entire duration of monitoring
  • The number of expected monitoring periods (e.g. 30-day periods) that the program seeks to establish for individuals with heart failure. The monitoring frequency should be at least 16 days for each 30-day period.  
  • How the program will track and improve outcomes including, but not limited to, the impacts on net health, individual experience (e.g., individual adherence), and equitable cost to demonstrate overall improvement (e.g., decrease in hospital re-admissions, cardiovascular-related mortality)
NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT
Remote patient monitoring is not eligible for separate reimbursement for the following: 
  • Remote patient monitoring for individuals located in any setting other than home (e.g., hospital)
  • Remote patient monitoring for individuals receiving duplicative monitoring services while under a home health, care management, or treatment plan of care.
  • Remote patient monitoring​ when the individual or caregiver(s) are not willing and are unable to participate and follow the treatment plan
  • Charges for telephone land lines, internet connections, telecommunication or cellular devices needed for operating the device performing the RPM
  • When the service is billed by more than one professional provider during a 30-day period 
  • When the monitoring frequency is less than 16 days during each 30-day period.
  • When no meaningful, measureable improvement has been documented in tracked outcomes for RPM program.   
​Remote patient monitoring (RPM) services that are not part of a Company-approved RPM program for acute decompensated heart failure are not eligible for separate reimbursement from other services (e.g. office visit and remote physiological monitoring)​ 
The rationale for RPM for more than two monitoring periods (i.e., 60 days) requires the medical record to reflect the individual's risk for heart failure–related hospitalization or emergency room visit based on a recognized risk calculator (e.g. 30-day Readmission Yale Core Risk Calculator).

BILLING REQUIREMENTS

Inclusion of a code in this policy does not impl​y reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
 
​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 health care professional'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.


Guidelines

BENEFIT APPLICATION
 
Subject to the terms and conditions of the applicable benefit contract, remote patient monitoring is covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

RPM supplements, rather than replaces, face-to-face provider visits.


Description

Remote patient monitoring (RPM), also known as telemonitoring (TM), is the collection and analysis of the individual's physiologic data (e.g., weight, blood pressure, pulse, pulse oximetry, and other condition-specific data) (remote physiologic monitoring) and the individual's adherence and response to therapy data​ (remote therapeutic monitoring) through a medical device, as defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act, that are used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition.  

RPM is not intended to be an ongoing modality; it is intended to be an intervention in response to a complication, decompensation, or instability of a medical condition. It may be u​​​​sed during the stabilization period, while an individual returns to the baseline of their condition, or establishes a new baseline. Once baseline is achieved, RPM is no longer an integral part of a plan of care.


RPM can reduce the number of hospitalizations, readmissions, and lengths of stay in hospitals, which help to ​​improve quality of life and contain costs.​


HEART FAILURE (HF)


The evidence for HF consists of systematic reviews,meta-analyses, and randomized controlled trials (RCTs). Recent systematic reviews and meta-analyses have shown a positive effect on HF-related admissions and mortality rates and all-cause mortality rates. It remains that a considerable proportion of the literature consists of low-quality and inconsistent evidence ab​​out the beneficial effects of RPM. Overall, the literature produced mixed results, with the best-quality evidence from RCTs has not been consistently favorable reporting between systematic reviews when comparing RPM to usual care for HF rates of all-cause and HF mortality, and all-cause and HF hospital admissions. RPM has been shown to lower the risk of all-cause and HF mortality, and all-cause and HF hospital admissions in cohort analyses and nonrandomized trials, results from larger-scale RCTs have demonstrated no or negative effects, and while other RCTs establish decrease​s in HF-related admissions, emergency department visits. Earlier publications reported fewer positive data.  More recently, evidence from RCTs have shown support for the use of RPM in the HF population. In aggregate, the evidence suggest that RPM may be considered as an adjunctive therapy for individuals with CHF and may result in positive overall net health outcomes.


Ong et al. (2016) randomly assigned 1437 individuals hospitalized for HF to the intervention arm (715 individuals) or to the usual care arm (722 individuals​) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life measures. 


The intervention combined health coaching telephone calls and TM. The TM arm utilized RPM electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. These measurements were analyzed by centralized registered nurses, who conducted RPM reviews, protocolized actions, and telephone calls.


The intervention and usual-care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of individuals, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P=0.74). In secondary analyses, there were not significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported in the trial associated with the treatment assignment. Among individuals previously hospitalized for HF, combined health coaching telephone calls and TM did not significantly reduce 180-day readmissions.


Koehler et al. (2018) report on a German, prospective, randomized, controlled, parallel-group, unmasked multicenter trial (n=1571). The primary outcome was percentage of days lost due to unplanned cardiovascular hospital admissions or all-cause death. Secondary outcomes were all-cause and cardiovascular mortality. A total of 765 individuals were assigned to the RPM group and 773 were in the usual-care group. The percentage of days lost due to unplanned cardiovascular hospital admissions and all-cause death was 4.88% (95% confidence interval [CI], 4.55–5.23) in the RPM group and 6.64% (6.19–7.13) in the usual-care group (ratio, 0.80; 95% CI, 0.65–1.00; P=0.0460). Individuals assigned to RPM reported an average loss of 17.8 days (95% CI, 16.6–19.1) per year to  24.2 days (22.6–26.0) per year, compared to those assigned to usual care. The all-cause death rate was 7.86 (95% CI 6·14–10·10) per 100 person-years of follow-up in the RPM group compared with 11.34 (9·21–13·95) per 100 person-years of follow-up in the usual-care group (hazard ratio [HR] 0.70; 95% CI, 0.50–0.96; P=0.0280).The authors reported that for cardiovascular mortality there was not a significantly difference between the two groups (HR, 0.671; 95% CI, 0.45–1.01; P=0·0560). Additional well-designed studies are required to validate reduction in hospitalizations for the HF population.


Yun et al. (2018) performed a systematic review and meta-analysis of TM versus usual care for HF. The researchers identified 37 studies (n=9582 individuals) for clinical effectiveness: mortality (n=24 studies), hospitalizations (n=17- all cause; 12 HF hospitalizations), and emergency room (ER) visits (n=5) and patient-reported outcomes. The risks of all-cause mortality (risk ratio [RR], 0.81, 95% CI, 0.70–0.94) and HF-related mortality (RR, 0.68; 95% CI, 0.50–0.91) were significantly lower in the monitoring group than in the usual-care arm. TM showed a significant benefit when >2 biometric data points are transmitted or when transmissions occurred daily. TM also reduced mortality risk in studies that monitored individuals' symptoms, medication adherence, or prescription changes. Daily transmission occurred in 28 studies, with another 3 studies reporting transmissions once- per week, and 5 studies were either uncategorized or two of the included studies report on data transmission.


The researchers found that TM interventions reduces the risk of mortality in individuals with HF, and intensive monitoring with more frequent transmissions of patient data increase that effectiveness. The authors demonstrated three or more measurable biometric data points measures resulted in the largest significant benefit in mortality risk for individuals with CHF.


Ding et al. (2020) conducted a multicenter RCT with a 6-month follow-up on 184 participants (141/184, 76.6% male), with a mean age of 70.1 (standard deviation [SD], 12.3) years. Participants were randomly assigned either to receive innovative TM-enhanced care (ITEC-CHF) (n=91) or usual care (control; n=93), of which 67 ITEC-CHF and 81 control participants completed the intervention.


For the compliance criterion of weighing at least 4 days per week, the proportion of compliant participants in the ITEC-CHF group was not significantly higher than that in the control group (ITEC-CHF: 67/91, 74% vs control: 56/91, 60%; P=0.06). However, the proportion of ITEC-CHF participants achieving the stricter compliance standard of at least 6 days a week was significantly higher than that in the control group (ITEC-CHF: 41/91, 45% vs control: 23/93, 25%; P=0.005). The ITEC-CHF treatment arm improved participant compliance with weight monitoring, although the withdrawal rate was high. RPM may be considered a promising method for supporting individuals in the management of CHF.  However, the researchers do note that further studies are required to optimize this model of care.


In a growing number of recent publications of systematic review, the research is suggesting that RPM may reduce all-cause hospitalizations, and mortality for individuals with heart failure. In a shift from prior recommendations, the American Heart Association (AHA, 2019), endorses the use of RPM in this vulnerable population.


Future research should focus on understanding the process by which RPM works in terms of improving HF-related outcomes, identify optimal strategies and the duration of follow-up for which it confers benefits, and further investigate whether there is differential effectiveness between chronic HF groups and various types of available RPM technologies.


References

American Heart Association. Using Remote Patient Monitoring Technologies for Better Cardiovascular Disease Outcomes Guidance. 2019. Available at: https://www.heart.org/-/media/files/about-us/policy-research/policy-positions/clinical care/remote-patient-monitoring-guidance-2019.pdf.


Bashi N, Karunanithi M, Fatehi F, et al. Remote monitoring of patients with heart failure: an overview of systematic reviews. J Med Internet Res. 2017;19:e18.


Bohm M, Drexler H, Oswald H, et al. Fluid status telemedicine alerts for heart failure: a randomized controlled trial. Eur Heart J. 2016;37:3154-63.


Boriani G, Da Costa A, Quesada A, et al. Effects of remote monitoring on clinical outcomes and use of healthcare resources in heart failure patients with biventricular defibrillators: results of the MORE-CARE multicentre randomized controlled trial. Eur J Heart Fail. 2017;19:416-25.


Brahmbhatt DH, Cowie MR. Remote management of heart failure: an overview of telemonitoring technologies. Card Fail Rev. 2019;5(2):86-92.


Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug; Payment for Office/ Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy; Coding and Payment for Virtual Check-in Services Interim Final Rule Policy; Coding and Payment for Personal Protective Equipment (PPE) Interim Final Rule Policy; Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID–19; and Finalization of Certain Provisions from the March 31st, May 8th and September 2nd Interim Final Rules in Response to the PHE for COVID–19. 12/28/2020. Available at: https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf. Accessed August 10, 2023.

Center for Outcomes Research and Evaluation (CORE). Readmission Risk Score for Heart Failure. Available at: http://www.readmissionscore.org/heart_failure.php. Accessed August 10, 2023.

Chaudhry SI, Mattera JA, Curtis JP, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363:2301-9.


Koehler F, Winkler S, Schieber M, et al.  Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. Circulation. 2011;123:1873-80.


De Simone A, Leoni L, Luzi M, et al. Remote monitoring improves outcome after ICD implantation: the clinical efficacy in the management of heart failure (EFFECT) study. Europace. 2015;17:1267-75.

Ding, H, Jayasena, R, Chen SH, et al. The effects of telemonitoring on patient compliance with self-management recommendations and outcomes of the Innovative Telemonitoring Enhanced Care Program for Chronic Heart Failure: Randomized Controlled Trial.  J Med Internet Res. 2020 Jul; 22(7):e17559. Available at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381046/.


Health Resources & Services Administration (HRSA). Telehealth and remote patient monitoring.05/11/2023. Available at: https://telehealth.hhs.gov/providers/preparing-patients-for-telehealth/telehealth-and-remote-patient-monitoring/. Accessed August 10, 2023​.


Kitsiou S, Pare G, Jaana M. Effects of home telemonitoring interventions on patients with chronic heart failure: an overview of systematic reviews. J Med Internet Res. 2015;17:e63.


Koehler F, Koehler K, Deckwart O, et al. Efficacy of telemedical interventional management in patients with heart failure (TIM-HF2): a randomized, controlled, parallel-group, unmasked trial. Lancet. 2018; 392(10152):1047-57.


Konstam V, Gregory D, Chen J, et al. Health-related quality of life in a multicenter randomized controlled comparison of telephonic disease management and automated home monitoring in patients recently hospitalized with heart failure: SPAN-CHF II trial. J Card Fail. 2011;17:151-7.


Kurek A, Tajstra M, Gadula-Gacek, et al. Impact of remote monitoring on long term prognosis in heart failure patients in a real-world cohort: results from All-Comers COMMIT-HF Trial. J Cardiovasc Electrophysiol. 2017;28:425-31.


Landolina M, Perego GB, Lunati M, et al. Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators: the evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study. Circulation. 2012;125:2985-92.


Liu S, Dunford SD, Leung YW, et al. Reducing blood pressure with Internet-based interventions: a meta-analysis. Can J Cardiol. 2013;29:613-21.


Mohebali D, Kittleson MM. Remote monitoring in heart failure: current and emerging technologies in the context of the pandemic. Heart. 2021;107:366-72.


Noah B, Keller MS, Mosadeghi S, et al. Impact of remote patient monitoring on clinical outcomes: an updated meta-analysis of randomized controlled trials. Available at: https://www.nature.com/articles/s41746-017-0002-4.pdf.


Ong MK, Romano PS, Edgington S, et al. Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial. JAMA Intern Med. 2016;176:310-8.


Piccini JP, Mittal S, Snell J, et al. Impact of remote monitoring on clinical events and associated health care utilization: A nationwide assessment. Heart Rhythm. 2016;13:2279-86.


van Veldhuisen DJ, Braunschweig F, Conraads V, et al. Intrathoracic impedance monitoring, audible patient alerts, and outcome in patients with heart failure. Circulation. 2011;124:1719-26.


Varma N, Piccini JP, Snell J, et al. The relationship between level of adherence to automatic wireless remote monitoring and survival in pacemaker and defibrillator patients. J Am Coll Cardiol. 2015;65:2601-10.


Vedel I, Khanassov V.  Transitional care for patients with CHF: A systematic review and meta-analysis. Ann Fam Med. 2015;13:562-71.


Coding

CPT Procedure Code Number(s)
NOT ELIGIBLE FOR REIMBURSEMENT

98975   

98976   

98977   

98980  

98981

99091   

99453   

99454   

99457   

99458


ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
I50.1 Left ventricular failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
​I50.84 End stage heart failure
I50.89 Other heart failure
I50.9 Heart failure, unspecified​

HCPCS Level II Code Number(s)

NOT ELIGIBLE FOR SEPARATE ​REIMBURSEMENT

S9110    Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per month​​


Revenue Code Number(s)
N/A

Policy History

Revisions From MA12.010b:
11/13/2024
This policy has been reissued in accordance with the Company's annual review process.
01/22/2024The policy was updated to:
  • ​Clarify the not eligible for reimbursement position 
  • Attach the attestation form that needs to be complete for remote patient monitoring program approval. ​
  • The coverage position for the following codes was changed from eligible to not eligible for separate reimbursement: 99091, 99453, 99454, 99457, 99458  ​

Revisions From MA12.010a:
​01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
04/01/2023The policy was updated to clarify the coverage and reimbursement position for remote therapeutic monitoring. 

Revisions From MA12.010:
01/23/2023This version of the policy will become effective 01/23/2023. 

The following new policy has been developed to address new and emerging technology. 

01/22/2024
01/22/2024
11/13/2024
MA12.010
Medical Policy Bulletin
Medicare Advantage
No