Clinical Medical Policy Department Clinical Affairs Division DESCRIPTION

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1 Ambulatory Blood Pressure Monitoring (ABPM) [For the list of services and procedures that need preauthorization, please refer to go to Comunicados a Proveedores, and click Cartas Circulares.] Medical Policy: MP-ME Original Effective Date: February 18, 2009 Revised: April 24, 2017 Next Revision: April, 2018 This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and, provider s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. DESCRIPTION Ambulatory Blood Pressure Monitoring (ABPM) is a medical device worn by the patient that takes Blood Pressure (BP) measurements over a 24 to 48 hour period, usually every 15 to 20 minutes during the daytime and every 30 to 60 minutes during sleep. These blood pressures are recorded on the device, and the average day (diurnal) or night (nocturnal) blood pressures are determined from the data by a computer. The percentage of BP readings exceeding the upper limit of normal can also be calculated (UpToDate /Kaplan, 2017). Ambulatory Blood Pressure Monitoring (ABPM) is being increasingly recommended for routine clinical practice (UpToDate /Kaplan, 2017). It provides valuable diagnostic information that in-clinic and home blood pressure monitoring systems are incapable of measuring including: Blood Pressure (BP) variability and a more accurate estimation of true blood pressure; Overnight changes in blood pressure (i.e., Dipper Status); and Morning surges in BP. In general, ABPM is recognized in the medical community as a valuable tool for supporting the management of appropriate pharmacologic treatment as well as the assessment of White Coat Hypertension (WCH); Resistant Hypertension; Masked Hypertension; Hypotensive symptoms with hypertensive medications (STM, 2016), all further defined under the Indications Section. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits, and coverage. 1

2 INDICATIONS, (MCS) considers medically necessary, for Both the Commercial and Classicare (Advantage) lines of business (LOB), the use of Ambulatory Blood Pressure Monitoring (ABPM) when ordered by a physician for the evaluation of Both Pediatric and Adult patients with Any of the following conditions: 1. Suspected White Coat Hypertension (WCH) defined as: a. Office blood pressure > 140/90 mmhg on a least three separate clinic/office visits with two separate measurements made at each visit; b. At least two documented separate blood pressure measurements taken outside the office which are < 140/90mm Hg; and c. No evidence of end-organ damage. 2. Resistant hypertension that is refractory to medication. 3. Hypotensive symptoms and/or syncopal events that are thought to be related to antihypertensive medications. 4. Episodic hypertension suspected when office blood pressure measurements are normal and symptoms suggest episodic hypertension secondary to an existing condition. 5. Suspected nocturnal hypertension. 6. When there is a large discrepancy between clinic and home BP measurements. 7. Management of isolated systolic hypertension in patients age 60 or older. 8. Autonomic Dysfunction. LIMITATIONS 1. The information obtained by ABPM is necessary in order to determine the appropriate management of the patient. ABPM is not covered for any other uses. 2. In the rare circumstance that ABPM needs to be performed more than once in a patient, the qualifying criteria described above must be met for each subsequent ABPM test. 3. The ABPM must be performed for at least 24 hours to meet coverage criteria. 2

3 4. ABPM is designated as an outpatient service; patients admitted to a hospital or residing in institutions, such as Skilled Nursing Facilities (SNFs), who receive ABPM, are not qualified for coverage. CODING INFORMATION FOR BOTH THE COMMERCIAL and CLASSICARE (ADVANTAGE) LOB CPT Codes (List may not be all inclusive) CPT Codes Description Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; recording only Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; review with interpretation and report Current Procedural Terminology (CPT ) 2017 American Medical Association: Chicago, IL. ICD-10 Codes (List may not be all inclusive) ICD-10 Codes I10 Essential (primary) hypertension Description I11.0 Hypertensive heart disease with heart failure I11.9 Hypertensive heart disease without heart failure I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney dis ease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney dis ease, 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 I15.0 Renovascular hypertension I15.1 Hypertension secondary to other renal disorders I15.2 Hypertension secondary to endocrine disorders 3

4 I15.8 Other secondary hypertension I15.9 Secondary hypertension, unspecified I95.1 Orthostatic hypotension N26.2 Page kidney R03.0 Elevated blood-pressure reading, without diagnosis of hypertension R55 Syncope and collapse REFERENCES 1. American Academy of Family Physicians (AAFP) (2005, February 1). Management of Hypertension in Older Persons. American Family Physician Volume 71, Issue 3, Pages Accessed April 13, Available at URL address: 2. American Academy of Family Physicians (AAFP) (2003, June 1). Automated Ambulatory Blood Pressure Monitoring: Clinical Utility in the Family Practice Setting. American Family Physician. Volume 67, Issue 11, Pages Accessed April 13, Available at URL address: 3. American Academy of Pediatrics (AAP) (2004, August 1). Supplement Article: The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Used Topic: ABPM. Pediatrics: Volume 114, Supplement Number 2, Pages Accessed April 13, Available at URL address: or 4. American Diabetes Association (ADA) (2013, August). Ambulatory Blood Pressure Monitoring (ABPM). Diabetes Care: Volume 36, Supplement 2, Pages S307 - S311. DOI: /dcS Accessed April 13, Available at URL address: and at URL address: 5. American Heart Association (AHA) (2014). Update: AHA Scientific Statement Update: Ambulatory Blood Pressure Monitoring in Children and Adolescents. Hypertension: 63: DOI: /HYP Page Accessed April 13, Available at URL address: and at URL address: 6. American Heart Association (AHA) (2013, December). Ambulatory Blood Pressure Measurement What Is the International Consensus? Page 990. Hypertension: 62: DOI: /HYPERTENSIONAHA Accessed April 13, Available at URL address: and at URL address: 4

5 7. Brown, M. (2014, January). Is there a role for Ambulatory Blood Pressure Monitoring (ABPM) in pregnancy? Clinical and Experimental Pharmacology and Physiology: 41 (1), DOI: / Accessed April 17, Available at URL address: 8. Centers for Medicare and Medicaid Services (CMS) (2016). Medicare Claims Processing Manual (CPM) Chapter 32- Billing Requirements for Special Services: Section Ambulatory Blood Pressure Monitoring (ABPM) Billing Requirements for Special Services. Rev. 3556, done 07/01/2016. Accessed April 17, Available at URL address: Guidance/Guidance/Manuals/downloads/clm104c32.pdf 9. Centers for Medicare and Medicaid Services (CMS) (2003). National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring (20.19). Version Number 2. Effective Date of this Version: 7/1/2003. Implementation Date: 7/1/2003. Accessed April 17, Available at URL address: European Society of Hypertension (ESH) with the European Society of Cardiology (ESC) (2013, July) ESH/ESC Guidelines for the management of arterial hypertension. The Task Force for the Management of Arterial Hypertension of ESH and of ESC. Journal of Hypertension Volume 31, Number 7, Pages Accessed April 17, Available at URL address: Journal of the American Medical Association (JAMA) (2014). Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA: Volume 311, Number Accessed April 17, Available at URL Address: National Heart, Lung, and Blood Institute (NIH) (2005). The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. NIH Publication No Originally printed September 1996 ( ). Revised: May Page 17 (Ambulatory Blood Pressure Monitoring). Accessed April 17, Available at URL address: and at URL address: National Heart, Lung, and Blood Institute (NIH) (2004, August). Complete Report - The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). NIH Publication No Page 19. Accessed April 17, Available at URL address: f, and at URL address: or at URL address: 5

6 14. Segura, J.; Banegas, J.; & Ruilope, L. (2014, January). Usefulness of ambulatory blood pressure monitoring (ABPM) in daily clinical practice: Data from the Spanish ABPM registry. Clinical and Experimental Pharmacology and Physiology Volume 41, Issue 1, Pages DOI: / Accessed April 17, Available at URL address: and at URL address: SunTech Medical, Inc. (STM) (2016). Ambulatory Blood Pressure Monitoring (ABPM). Accessed April 17, Available at URL address: UpToDate /Kaplan, N. (2017). Ambulatory blood pressure monitoring and white coat hypertension in adults. Literature review current through: March This topic last updated: October 13, Accessed April 17, Available at URL address: UpToDate /Flynn, J. (2017). Ambulatory blood pressure monitoring in children. Literature review current through: March This topic last updated: March 23, Accessed April 17, Available at URL address: =2~ WebMD LLC. / Matthew, A. & Yang, e. (2017). Hypertension Differential Diagnoses Updated: March 23, Accessed April 17, Available at URL address: POLICY HISTORY DATE ACTION COMMENT February 18, 2009 Origination of Policy February 18, 2010 Revised Ambulatory Blood Pressure Monitoring is revised to add the contraindications and limitations. February 18, 2011 Yearly Revision Experimental/Experimental list added. January 12, 2012 Yearly Revision References Updated. February 25, 2013 Revised References Updated. Added new reference, number 6. To the Indications Section: Added Indication # 8. February 21,2014 Revised To the Coding section: A new ICD-10 Codes (Preview Draft) section was added to the policy. April 10, 2014 Revised References Updated. Added new references, numbers 1-3, 5-11, 13-16, 18-23, 26-32, and 34. To the Descriptions Section: Deleted: The percentage of patients presenting hypertension 6

7 signs has increased and as a result patients are exposed to organ damage, higher risks for strokes, heart disease, heart attacks, and kidney failure. Deleted: High blood pressure usually has no symptoms and controlling hypertension can become challenging. Therefore, the physician along with the patient must work together to find the best way to lower blood pressure. The only way to find out the blood pressure (BP) is too high is to check it with a pressure monitor. The higher the BP is the more often should be check. Deleted: Blood Pressure (BP) as recorded in the office setting is the standard technique recommended for the measurement of BP in routine medical care. The standard technique for the auscultatory method of BP measurement in the office setting requires a properly calibrated and validated instrument; the patient seated quietly for at least five minutes in a chair rather than on the examination table, with feet on the floor and arm supported at heart level. At least two measurements should be made on each of two or more office visits. The mean of those readings should be recorded and given to the patient along with the goals for blood pressure management. Deleted: Office or clinic blood pressure measurements have limitations; blood pressure fluctuates throughout the day and specific ranges are associated with normal, hypertension and hypotension. On the other hand, some patients, elevated blood pressure may only be detected in the physician office and this pattern can be in response to the medical environment (condition known as white coat hypertension). Because of this, the numbers of measurements obtained in the office may not always reflect a patient s true average blood pressure. Deleted: Ambulatory blood pressure monitoring (ABPM) is a noninvasive method of measuring regular blood pressure readings, regularly over a 24-hour period, as patients conduct their normal activities. A special, automatic blood pressure monitor is used, and patients are asked to keep a diary or log of their activities. These 24-hour measurements are stored in the device and are later interpreted by the physician. Deleted: ABPM devices consist of an inflatable cuff with pressure regulators and valves to measure BP, a cuff microphone or sound transducer and microprocessor to detect and interpret BP sounds, mechanisms for programming and recording BP readings, and an inflation bulb for semiautomatic devices. There are various types of devices including: fully automated, which inflate at pre-programmed intervals; semiautomated, which are patient-activated; and transtelephonic, which allow the use of telephones to transmit measured automatic digital readings to a computer-assisted receiver. The devices are lightweight and quiet and use auscultatory or oscillometric methods, or both. Added: Hypertension, or high blood pressure, is a chronic condition defined by elevated blood pressure in the arteries. Normal blood pressure at rest is usually 100 to 140 mm Hg systolic and 60 to 90 mm Hg diastolic. Because hypertension is asymptomatic, it can be detected only by screening. Simple blood-pressure cuff tests are routinely performed as part of most physical exams. However, office assessments of blood pressure may not be very accurate: the manual cuffs require subjective assessment, many people develop temporary blood pressure elevations in doctor s offices (i.e., white coat hypertension ), and definitive changes in blood pressure occur throughout the day due to the circadian rhythm. One possible approach to obtaining reliable blood pressure measurements is through continuous Ambulatory Blood Pressure Monitoring 7

8 (ABPM). Added: Ambulatory Blood Pressure Monitoring (ABPM) is a noninvasive, fully-automated technique in which blood pressure is recorded over an extended period of time, typically 24 hours. The APBM device is a wearable blood pressure cuff or finger-cuff with a monitor. During a typical ABPM session, the device will inflate the cuff and measure blood pressure every 15 to 30 minutes over a 24-hour period, including both awake and asleep hours, preferably on a workday. The total number of readings usually varies between 50 and 100. Blood pressure data are stored in a monitor and then downloaded and analyzed using device-specific computer software. In general, ABPM devices consist of a standard blood-pressure cuff attached to a small computer, which the user wears at the waist or on a shoulder strap. The patient wears the device continuously for 24 hours, during which the monitor collects information on blood pressure multiple times (ECRI, 2013). To entire medical policy: Changed the word member to the word patient. June 27, 2015 Revised To the References Section: References updated. Deleted obsolete, unavailable and non-used references for 2015 revision. Added new references, numbers 5, 11, and 15. To the Description Section: Deleted entire previous information. Added: Ambulatory Blood Pressure Monitoring (ABPM) is determined using a device worn by the patient that takes Blood Pressure (BP) measurements over a 24- to 48-hour period, usually every 15 to 20 minutes during the daytime and every 30 to 60 minutes during sleep. These blood pressures are recorded on the device, and the average day (diurnal) or night (nocturnal) blood pressures are determined from the data by a computer. The percentage of BP readings exceeding the upper limit of normal can also be calculated (UpToDate /Kaplan, 2015). Added: Ambulatory Blood Pressure Monitoring (ABPM) is being increasingly recommended for routine clinical practice (UpToDate /Kaplan, 2015). It provides valuable diagnostic information that in-clinic and home blood pressure monitoring systems are incapable of measuring including: Blood Pressure (BP) variability and a more accurate estimation of true blood pressure; Overnight changes in blood pressure (i.e., Dipper Status); and Morning surges in BP. In general, ABPM is recognized in the medical community as a valuable tool for supporting the management of appropriate pharmacologic treatment as well as the assessment of: White Coat Hypertension (WCH); Resistant Hypertension; Masked Hypertension; and Hypotensive symptoms with hypertensive medications (STM, 2015), all further defined under the Indications Section. To the Indications Section: Restructured coverage statement as follows: For Both the Commercial and Classicare (Advantage) Lines of Business (LOB):, (MCS) considers medically necessary the use of Ambulatory Blood Pressure Monitoring (ABPM) when ordered by a physician for the evaluation of Both Pediatric and 8

9 Adult patients with Any of the following conditions. To the Experimental/Investigational/Unproven Section: Deleted entire section, based on content of Limitation #1 (i.e., ABPM is not covered for any other uses). To the Limitations Section: Revised and restructured content of Limitation #4 as follows: ABPM is designated as an outpatient service; patients admitted to a hospital or residing in institutions, such as Skilled Nursing Facilities (SNFs), who receive ABPM, are not qualified for coverage. Deleted Limitation #5: A physician is required to perform the interpretation of the data obtained through ambulatory blood pressure monitoring. There are no requirements regarding the setting in which the interpretation is performed. To the Coding Information: Clarification was made that Coding Information applies to Both LOB. To the ICD-9-CM Codes Section, added codes: and To the ICD-10 Codes Section, added codes: I95.89 and I95.9. November 23, 2015 Revised To the coding section: Eliminate ICD-9 codes since they are no longer valid for diagnosis classification. Add new section of ICD-10 codes which are the valid diagnosis classification system since October 1, March 30, 2016 Revised References were Updated. April 24, 2017 Revised References were Updated. To the References Section: New Reference #12 was added to the Policy. To the Description section: Phrase determined using was deleted and a new phrase was added to the first paragraph. To the References Section: Reference #8 and 16 were deleted from this Policy. This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member s plan in effect as of the date services are rendered., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion., (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan s ability to interpret plan language as deemed appropriate. 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 they choose to provide. 9

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