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Automated Ambulatory Blood Pressure

Policy Number: MP-128

Refer to the Health Care Reform Preventive Care Services Coding document.

Latest Review Date: June 2020

Category:   Medicine                                                             

Policy Grade:  B 

 

 

POLICY:

Effective for dates of service on and after July 1, 2019:

 

Note: Ambulatory blood pressure monitoring for less than 24 hours or more than 3 days is not considered medically necessary.

 

For eligible patients, ABPM is covered once per year.

 

Refer to HealthCareReform on the Provider Access/Resources/Programs & Initiatives page for the Quick Reference Guide for HCR Preventive Care Services

 

Automated Ambulatory Blood Pressure Monitoring may be considered medically necessary when performed over a 24-hour period for the evaluation of individuals with any of the following:

 

  • To confirm the diagnosis of episodic hypertension due to symptomatology (paroxysms of excessive sweating, palpitations, apprehension) suggests episodic hypertension secondary to an adrenal tumor (e.g., pheochromocytoma), and office blood pressure measurements are repeatedly normal; OR

 

  • To evaluate hypotensive symptoms and/or syncopal events that are thought to be related to anti-hypertensive medications; OR

 

  • To evaluate syncope when used in conjunction with a 24-hour Holter monitor to determine whether symptoms of syncope or near syncope are the direct result of an arrhythmia; OR

 

  • To evaluate blood pressure changes in those with nocturnal angina; OR

 

  • Prior to instituting an invasive investigation (e.g., renin vein assays, angiogram for renal artery stenosis) for secondary causes of hypertension for members with hypertension that is refractory to medications; OR

 

  • In patients who remain hypertensive despite being treated with 3 or more antihypertensive medications at therapeutic doses.

 

 

PEDIATRICS

For pediatric patients, Automated Ambulatory Blood Pressure Monitoring may be considered medically necessary for a 24-hour period for patients with elevated office blood pressure (BP), when performed to differentiate between “white coat” hypertension and true hypertension when all of the following conditions are met:

 

  • Office blood pressure elevation beyond the pediatric normative threshold levels (greater than 90th percentile for age, gender and height in children), not requiring immediate treatment with medication, AND

  • There is no hypertensive end-organ damage on physical exam and laboratory testing,

 

AND with the following special considerations:

 

  • A device should be selected that is appropriate for use in pediatric patients, including use of a cuff size appropriate to the child’s size, AND

  • Threshold levels for the diagnosis of hypertension should be based on pediatric normative data, which use gender and height specific values derived from large pediatric populations, AND

  • Must meet recommendations from AHA guidelines concerning classification of hypertension in pediatric patients using clinic and ambulatory BP are given in the following table:

Classification

Clinic Blood Pressure

Mean Ambulatory SBP

a

SBP Load, %

Normal blood pressure

<95th percentile

<95th percentile

<25

White coat HTN

>95th percentile

<95th percentile

<25

Masked HTN

<95th percentile

>95th percentile

>25

Pre-HTN

>95th percentile

<95th percentile

25-50

Ambulatory HTN

>95th percentile

>95th percentile

25-50

Severe Ambulatory HTN

>95th percentile

>95th percentile

>50

 

Effective for dates of service prior to May 1, 2019:

Automated Ambulatory Blood Pressure Monitoring may be considered medically necessary for a onetime 24-hour period for patients with elevated office blood pressure (BP), when performed to differentiate between “white coat” hypertension and true hypertension when all of the following conditions are met:

 

  • Office blood pressure elevation is in the mild to moderate range (<180/110), not requiring immediate treatment with medication; AND

  • There is no hypertensive end-organ damage on physical exam and laboratory testing.

 

For pediatric patients, Automated Ambulatory Blood Pressure Monitoring may be considered medically necessary for a onetime 24-hour period for patients with elevated office blood pressure (BP), when performed to differentiate between “white coat” hypertension and true hypertension when all of the following conditions are met:

 

  • Office blood pressure elevation beyond the pediatric normative threshold levels, not requiring immediate treatment with medication, AND

  • There is no hypertensive end-organ damage on physical exam and laboratory testing,

 

AND with the following special considerations:

 

  • A device should be selected that is appropriate for use in pediatric patients, including use of a cuff size appropriate to the child’s size, AND

  • Threshold levels for the diagnosis of hypertension should be based on pediatric normative data, which use gender and height specific values derived from large pediatric populations, AND

  • Must meet recommendations from AHA guidelines concerning classification of hypertension in pediatric patients using clinic and ambulatory BP are given in the following table:

 

Classification

Clinic Blood Pressure

Mean Ambulatory SBP

SBP Load, %a

Normal blood pressure

<95th percentile

<95th percentile

<25

White coat HTN

>95th percentile

<95th percentile

<25

Masked HTN

<95th percentile

>95th percentile

>25

Pre-HTN

>95th percentile

<95th percentile

25-50

Ambulatory HTN

>95th percentile

>95th percentile

25-50

Severe Ambulatory HTN

>95th percentile

>95th percentile

>50

 

All other uses of Automated Ambulatory Blood Pressure Monitoring for patients with elevated office BP, including but not limited to, repeated testing in patients with elevated office BP, and monitoring of treatment effectiveness, are considered not medically necessary and investigational.

 

 

 

DESCRIPTION OF PROCEDURE OR SERVICE:

Ambulatory blood pressure (BP) monitors (24-hour sphygmomanometers) are portable devices that continually record BP while the patient is involved in daily activities. There are various types of ambulatory monitors; this evidence review addresses fully automated monitors, which inflate and record BP at preprogrammed intervals. Ambulatory blood pressure monitoring (ABPM) has the potential to improve the accuracy of diagnosing hypertension and thus improve the appropriateness of medication treatment.

 

Typically done over a 24 hour period with a fully automated device, ABPM provides more detailed BP information than readings typically obtained during office visits.  The greater number of readings with ABPM ameliorates the variability of single BP measurements and is more representative of the circadian rhythm of BP. Various BP indexes can be derived from the detailed BP information provided by ABPM, including multiple measure times (e.g., 24 hours, daytime, nighttime) and dipping ratio (i.e., calculated by dividing nighttime by daytime systolic BP). Studies evaluating the comparative clinical utility of the various available ABPM BP indexes have suggested that higher 24-hour and nighttime BP indexes may marginally improve model predictions of greater risk of death and composite cardiovascular events.

 

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 assessing patients with elevated office blood pressure, ABPM is often intended to identify patients with normal ambulatory readings who do not have sustained hypertension. Because 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.

 

For additional information regarding white coat hypertension, please refer to HealthCareReform on the Provider Access/Resources/Programs & Initiatives page for the Quick Reference Guide for HCR Preventive Care Services.

 

Additional uses of ABPM include confirming the diagnosis of episodic hypertension; evaluating whether symptoms such as lightheadedness or syncope correspond with blood pressure changes; evaluating nighttime blood pressure; or evaluating refractory or resistant blood pressure.

 

 

KEY POINTS:

The most recent literature review was updated through April 15, 2020.

 

Summary of Evidence

For individuals with elevated office BP who receive 24-hour automated ABPM, the evidence includes randomized controlled trials, cohort studies, and studies of diagnostic accuracy. Relevant outcomes are test accuracy, other test performance measures, morbid events, and medication use. Data from large prospective cohort studies have established that ABPM correlates more strongly with cardiovascular outcomes than with other methods of BP measurement. When compared directly with other methods, ABPM performed over a 24-hour period has higher sensitivity, specificity, and predictive value for the diagnosis of hypertension than office or home BP measurements. Substantial percentages of patients with elevated office BP have normal BP on ABPM (WCH). Prospective cohort studies have reported that patients with WCH have an intermediate risk of cardiovascular outcomes compared with normotensive and hypertensive patients. The benefit of medication treatment in these patients is uncertain, and they 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 unnecessary pharmacologic treatment and avoiding adverse events in patients not expected to benefit. The evidence is sufficient to determine qualitatively that the technology results in a meaningful improvement in the net health outcome.

 

Practice Guidelines and Position Statements

American Academy of Pediatrics

The American Academy of Pediatrics published clinical guidelines for the screening and management of high blood pressure (BP) in children and adolescents in 2017. Table 1 lists recommendations made.

 

Table 1. Guidelines on Screening and Management of High BP in Children and Adolescents

Recommendation

LOE

SOR

“ABPM should be performed for confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for 1 year or more or with stage 1 HTN over 3 clinic visits.”

C

Moderate

“Routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk for target organ damage.”

B

Moderate

“ABPM should be performed by using a standardized approach with monitors that have been validated in a pediatric population, and studies should be interpreted by using pediatric normative data.”

C

Moderate

“Children and adolescents with suspected WCH should undergo ABPM.”

B

Strong

ABPM: ambulatory blood pressure monitoring; BP: blood pressure; DBP: diastolic blood pressure; HTN: hypertension; LOE: level of evidence; SBP: systolic blood pressure; SOR: strength of recommendation; WCH: white coat hypertension

 

 

American College of Cardiology et al

The American College of Cardiology, with 10 other medical specialty societies, published guidelines on the prevention, detection, evaluation, and management of high BP in adults in 2017. Table 2 lists recommendations made.

 

Table 2. Guidelines on Prevention, Detection, Evaluation, and Management of High BP in Adults

Recommendations

COR

LOE

“In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or DBP greater than 80 mm Hg but less than 100 mm Hg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ABPM or HBPM before diagnosis of hypertension”

IIa

B-NR

“In adults with white coat hypertension, periodic monitoring with either ABPM or HBPM is reasonable to detect transition to sustained hypertension”

IIa

C-LD

“In adults being treated for hypertension with office BP readings not at goal and HBPM readings suggestive of a significant white coat effect, confirmation by ABPM can be useful”

IIa

C-LD

“In adults with untreated office BPs that are consistently between 120 mm Hg and 129 mm Hg for SBP or between 75 mm Hg and 79 mm Hg for DBP, screening for masked hypertension with HBPM (or ABPM) is reasonable”

IIa

B-NR

“In adults on multiple-drug therapies for hypertension and office BPs within 10 mm Hg above goal, it may be reasonable to screen for white coat effect with HBPM (or ABPM)”

IIb

C-LD

ABPM: ambulatory blood pressure monitoring; COR: class of recommendation; DBP: diastolic blood pressure; HBPM: home blood pressure monitoring; LOE: level of evidence; SBP: systolic blood pressure.

 

American Heart Association

The American Heart Association published consensus recommendations in children and adolescents in 2014. Consensus recommendations for routine ABPM included the following:

 

  • “To confirm the diagnosis of hypertension in a patient with hypertension according to casual BP measurements
    • Determine whether sustained hypertension or white coat hypertension exists.
  • To evaluate for the presence of masked hypertension when there is a clinical suspicion of hypertension but normal or pre-hypertensive casual measurements
  • To assess BP patterns in high-risk patients
  • Assess for abnormal circadian variation in BP, such as blunted dipping or isolated sleep hypertension in patients with diabetes mellitus, chronic kidney disease, solid organ transplants, and severe obesity with or without sleep-disordered breathing.
  • Assess the severity and persistence of BP elevation in patients at high risk for hypertensive target-organ damage.
  • To evaluate effectiveness of drug therapy for hypertension
    • Confirm BP control in treated patients, especially those with secondary forms of hypertension.
    • Evaluate for apparent drug-resistant hypertension.
    • Determine whether symptoms can be attributed to drug-related hypotension.”

 

In 2019, the American Heart Association published a new scientific statement on blood pressure monitoring in humans that provides an overview about blood pressure measurement overall. This scientific statement includes a summary of current knowledge about ambulatory blood pressure monitoring on topics such as medical staff or provider training; devices, cuffs and equipment; patient preparation and instruction; frequency and number of readings; duration of monitoring, and analysis of readings.

 

National Institute for Health and Clinical Excellence

In 2016 and 2019, the National Institute for Health and Care Excellence (NICE) updated its 2011 guidance on hypertension. For diagnosing hypertension, the NICE made the following recommendations for ambulatory blood pressure monitoring (ABPM)

  • "If the clinic blood pressure is between140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
  • If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension
  • When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours to confirm a diagnosis of hypertension.”
  • Confirm diagnosis of hypertension in people with a clinic blood pressure of 140/90 mmHg or higher AND ABPM daytime average or HBPM average of 135/85 mmHg or higher

 

U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF) published a recommendation in 2015 for hypertension. The following recommendation was given a grade A rating:

“The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.”

 

The document further elaborated on the choice of office measurements, with the following statement about ABPM:

“The USPSTF found convincing evidence that ABPM is the best method for diagnosing hypertension. Although the criteria for establishing hypertension varied across studies, there was significant discordance between the office diagnosis of hypertension and 12- and 24-hour average blood pressures using ABPM, with significantly fewer patients requiring treatment based on ABPM. Elevated ambulatory systolic blood pressure was consistently and significantly associated with increased risk for fatal and nonfatal stroke and cardiovascular events, independent of office blood pressure. For these reasons, the USPSTF recommends ABPM as the reference standard for confirming the diagnosis of hypertension.”

 

 

KEY WORDS:

Automated ambulatory blood pressure monitoring, ABPM, 24-hour sphygmomanometers

 

 

APPROVED BY GOVERNING BODIES:

Many ABPMs have received clearance to market through the 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.

 

 

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts:  Special benefit consideration may apply.  Refer to member’s benefit plan.  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. 

 

 

CURRENT CODING:

CPT codes:   

93784

Ambulatory blood pressure monitoring, utilizing report generating software, automated, worn continuously for 24 hours or longer; including recording, scanning analysis, interpretation and report

93786

; Recording only

93788

; Scanning analysis with report

93790

; Review with interpretation and report

 

 

These separate CPT codes may be used if different individuals perform the individual tasks. However, if one physician performs all of the above services, CPT code 93784 may be used. Code 93784 is a comprehensive code describing recording, scanning analysis, and interpretation and report.

 

 

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  73. Valent-Moric B, Zigman T, Zaja-Franulovic O et al. The importance of ambulatory blood pressure monitoring in children and adolescents. Acta Clin Croat 2012; 51(1):59-64.
  74. Verdecchia P, Palatini P, Schillaci G et al. Independent predictors of isolated clinic ('white-coat') hypertension. J Hypertens 2001; 19(6):1015-20.
  75. Verdecchia P, Porcellati C, Schillaci G et al. Ambulatory blood pressure. An independent predictor of prognosis in essential hypertension. Hypertension 1994; 24(6):793-801.
  76. Verdecchia P, Reboldi GP, Angeli F et al. Short- and long-term incidence of stroke in white-coat hypertension. Hypertension 2005; 45(2):203-8.
  77. Verdecchia P. Reference values for ambulatory blood pressure and self-measured blood pressure based on prospective outcome data. Blood Pressure Monitoring, December 2001, Vol. 6, No. 6. (Abstract)
  78. Weber Michael A. The 24-hour blood pressure pattern: Does it have implications for morbidity and mortality? The American Journal of Cardiology, January 2002, Vol. 89, No. 2A.
  79. Weisser B, Mengden T, Dusing R et al. Normal values of blood pressure self-measurement in view of the 1999 World Health Organization-International Society of Hypertension guidelines. Am J Hypertens 2000; 13(8):940-3.
  80. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. May 15 2018; 71(19):2199-2269.
  81. Williams B, Poulter NR, Brown MJ et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18(3):139-85.  
  82. Yang WY, Melgarejo JD, Thijs L, et al. Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes. JAMA. Aug 06 2019; 322(5): 409-420.

 

 

POLICY HISTORY:

Medical Policy Group, September 2003

Medical Policy Administration Committee, September 2003

Available for comment September 8-October 22, 2003

Medical Policy Group, July 2005 (1)

Medical Policy Group, July 2007 (1)

Medical Policy Group, August 2008 (3)

Medical Policy Group, August 2010 (1): No new info to change coverage statement

Medical Policy Group, March 2012 (3): 2012 Updates: Policy, Key Points, Key Words, References

Medical Policy Administration Committee, March 2012

Available for comment March 28 through May 14, 2012

Medical Policy Panel, December 2012.

Medical Policy Group, December 2012 (3): 2012 Updates:  Key Points, Summary, References. Policy statement remains unchanged

Medical Policy Group, December 2012 (3): 2013 Coding Update – Code 93790-removed “physician”.

Medical Policy Panel, December 2013

Medical Policy Panel, January 2014

Medical Policy Panel, January 2015

Medical Policy Group, January 2015 (4): 2013, 2014 and 2015 updates to Description, Key Points and References.  Updated Policy section with ABPM for pediatrics

Medical Policy Administration Committee, February 2015

Available for comment January 30 through March 15, 2015

Medical Policy Panel, July 2016

Medical Policy Group, October 2016 (4): Updates to Key Points and References; removed policy statements that were effective prior to 3/2012. No change to policy statement.

Medical Policy Panel, June 2017

Medical Policy Group, June 2017 (4) Updates to Description, Key Points, and References. No change to policy statement.

Medical Policy Panel, June 2018

Medical Policy Group, July 2018 (4): Updates to Description, Key Points, and References.  No change to policy statement.  Removed policy statements for effective dates of service March 28, 2012 through January 31, 2015:

Medical Policy Panel, June 2019

Medical Policy Group, July 2019 (4): updates to Description, Policy, Key Points, and References.  Policy statements updated to include coverage for additional criteria such as episodic hypertension, evaluate hypotensive symptoms and/or syncopal events, and nocturnal angina.  Added statement to refer to HCR document for WCH.

Medical Policy Administrative Committee: July 2019

Available for Comment July 9, 2019 through August 23, 2019.

Medical Policy Group, December 2019: 2020 Annual Coding Update.  Updated description for revised codes 93784 and 93790.

Medical Policy Panel, June 2020

Medical Policy Group, June 2020 (4): Updates to Key Points and References.  No change to policy statements.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

 

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.