Clinical Policy Title: Ambulatory blood pressure monitoring

Transcription

1 Clinical Policy Title: Ambulatory blood pressure monitoring Clinical Policy Number: Effective Date: October 1, 2014 Initial Review Date: May 21, 2014 Most Recent Review Date: May 19, 2017 Next Review Date: May 2018 Policy contains: Ambulatory blood pressure monitoring. White coat hypertension. Masked hypertension. Related policies: CP# CP# Implantable cardiac loop recorder Real-time outpatient cardiac monitoring ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas considers the use of 24-hour ambulatory blood pressure monitoring (ABPM) to be clinically proven and, therefore, medically necessary to assist in the diagnosis of hypertension (HTN) when all of the following criteria are met: No evidence of end-organ damage. The information obtained by ABPM is necessary to determine appropriate patient management. For either of the following indications: - Suspected white coat HTN (WCH). WCH is defined as: In adults, an office blood pressure (BP) > 140/90 mm Hg on at least three separate office or clinic visits, with two separate measurements made at each visit, and at least two documented BP measurements taken outside the office that are < 140/90 mm Hg. 1

2 In children, greater than 95th percentile for age, gender, and height on at least three separate physician office visits with two separate measurements taken at each visit. - Suspected masked HTN or masked, uncontrolled (treated) HTN with documented clinical suspicion of HTN (e.g., left ventricular hypertrophy) and either: A normal office BP < 140/90 mm Hg in untreated individuals. An office BP mm Hg/80 89 mm Hg in individuals treated with antihypertensive medicine. For Medicare members only: AmeriHealth Caritas considers the use of ABPM to be medically necessary for patients with suspected WCH who meet all of the following criteria: Office BP > 140/90 mm Hg on at least three separate clinic or office visits with two separate measurements made at each visit. At least two documented BP measurements taken outside the office that are < 140/90 mm Hg. No evidence of end-organ damage. Limitations: All other uses of ABPM are not medically necessary. The following quality criteria for ABPM must be met: ABPM is performed for at least 24 hours. Automatic readings are set at 30-minute intervals. ABPM is performed using a U.S. Food and Drug Administration (FDA)-approved device that has been validated according to international, standardized protocols prior to use. Repeat ABPM may be obtained if the first examination has less than 70 percent of the expected values due to a high number of artifacts. Routine repeat ABPM is not clinically proven and, therefore, not medically necessary. In a circumstance when ABPM needs to be performed more than once on a patient, the medical necessity and quality criteria described above must be met for each subsequent ABPM test. Alternative covered services: Office or clinic BP measurement. Home BP measurement (HBPM). Background 2

3 HTN is a common chronic health condition in the United States. The prevalence of HTN is approximately 30 percent in adults (ages 18 and older) and 3 percent 4 percent in children (Gillespie, 2013; National Heart, Lung, and Blood Institute [NHLBI], 2005). HTN is a major risk factor for heart disease and stroke, and BP control among those with HTN can reduce the risk of subsequent cardiovascular diseases (Chobanian, 2003). Primary (essential) HTN is now identifiable in children and adolescents and is often associated with a positive family history of HTN or cardiovascular disease, obesity, and lifestyle factors (NHLBI, 2005; Flynn, 2014). HTN is defined as persistently high systemic arterial BP based on multiple readings, and is classified as follows (NHLBI, 2005): Pre-HTN: systolic BP (SBP) of mm Hg and diastolic BP (DBP) of mm Hg. Stage 1 HTN: in adults, SBP of mm Hg and DBP of mm Hg; in children, an average BP level from the 95th percentile to 5 mm Hg above the 99th percentile. Stage 2 HTN: SBP of 160 mm Hg or DBP of 100 mm Hg; in children, an average BP that exceeds 5 mm Hg above the 99th percentile. Accurate BP measurement is essential to classify individuals, ascertain BP-related risk, and guide management. To date, office BP measurements define the relationship between BP and risk (Pickering, 2005; NHLBI, 2005). BP fluctuates substantially throughout a typical day, from day to day, and over longer periods of time. Multiple factors contribute to these fluctuations, including WCH, which may be present in 20 percent to 35 percent of patients diagnosed with HTN. Out-of-office HTN in the presence of non-elevated clinic BP measurement is also a growing public health concern. Masked HTN is present in a high percentage of untreated patients and an even higher percentage of patients after beginning antihypertensive medication (Franklin, 2016). The term masked HTN is often used to describe out-of-office HTN in untreated individuals, reserving the term masked uncontrolled HTN or MUCH for those who are on antihypertensive medicine. Differentiating treated and untreated persons with masked HTN is necessary, as the treatment strategies differ between the two groups. Therefore, a diagnosis of WCH or masked HTN requires repeated measurements to minimize misclassification of individuals as hypertensive or normotensive (Pickering, 2005). ABPM: ABPM is a noninvasive method of obtaining multiple BP readings at regular intervals over a 24-hour (or sometimes 48-hour) period in the person s own living environment. ABPM collects data during daily activities and sleep, ostensibly representing a true reflection of the individual s BP. The rationale for using ABPM within carefully selected populations is to provide more precise and accurate BP data that will help simplify or eliminate drug therapy and reduce medication consumption and related complications, resulting in improved outcomes and overall cost savings. The purported clinical advantages of ABPM are to (Pickering, 2005): Detect lower BP (WCH) or higher BP (masked HTN) out-of-office compared to in-office measurement. 3

4 Determine the presence or absence of normal nocturnal dipping status (i.e., decreases in an individual s BP during nighttime hours or when sleeping). Assess the adequacy of BP control in persons taking complex antihypertensive medication regimens. Provide detailed information on BP patterns in persons with episodic HTN, chronic kidney disease, diabetes, and autonomic dysfunction. Identify persons with apparently refractory HTN but relatively little to no target organ damage. Confirm HTN in patients in whom there is a large discrepancy between clinic and home BP measurements. Table 1 illustrates the lack of consensus among guidelines regarding the definition of HTN in adult populations according to ABPM. Instead, guidelines use thresholds based on a definition of HTN (BP > 140/90 mm Hg) obtained in an office setting from clinical trials that examined the benefits of treating HTN. Less robust data exist to support treatment guidelines using ABPM (Meyers, 2011). Table 1. Diagnostic thresholds for HTN using ABPM in adults ABPM (mm Hg) Joint National Committee 7 (Chobanian, 2003) American Heart Association (AHA) (Pickering, 2005) National Institute for Health and Clinical Excellence (NICE) (2011) Canadian Hypertension Education Program (CHEP) (2014) European Society of HTN and European Society of Cardiology (Mancia, 2013) 24-hour > 135/85 130/80 130/80 Daytime > 135/85 > 140/90 135/85 135/85 135/85 Nighttime > 120/75 > 125/75 120/70 In pediatric populations, an AHA consensus statement defines HTN as a mean ambulatory SBP or DBP, or both, > 95th percentile with an elevated SBP or DBP load 25 percent (Flynn, 2014). However, they acknowledge deficiencies in the research of HTN management in pediatric populations, particularly using ABPM. The AHA stresses the urgent need for more comprehensive normative ABPM data across sexes, races, and ages; devices that can measure DBP more accurately; and robust data linking ABPM patterns to target organ damage (Flynn, 2014). In the United States, several ABPM monitors have been cleared for marketing via the 510(k) process (FDA, 2017). However, monitors that have not undergone validation testing or FDA clearance can be sold in the United States, and few have been formally validated in children (Flynn, 2014). Searches AmeriHealth Caritas searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. 4

5 Agency for Healthcare Research and Quality s (AHRQ s) Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on March 28, Search terms were: blood pressure monitoring, ambulatory (MeSH) and hypertension/diagnosis (MeSH). We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings For this policy, we included only studies published since 2000 to reflect the most current research in the U.S. context. AmeriHealth Caritas identified six systematic reviews and one health technology assessment that addressed the diagnostic accuracy, prognostic value, and cost-effectiveness of ABPM in managing adults with HTN. No systematic reviews addressed ABPM in pediatric populations. The overall quality of the evidence comparing ABPM to clinic BP measurement or home BP measurement consisted of three randomized controlled trials (RCTs), multiple cross-sectional studies, and multiple prospective observational studies of generally poor to moderate quality. Heterogeneity in study designs limited comparison of results across studies. There is sufficient evidence to support the safety, efficacy, and cost-effectiveness of ABPM to confirm the presence or absence of WCH in persons with elevated BP measured by office-based screening. More recent evidence-based guidelines are notably consistent in defining suspected WCH as > 140/90 mm Hg in the clinic and < 135/85 mm Hg outside the clinic (NICE, 2011; Mancia, 2013; CHEP, 2014). Evidence suggests an association between WCH and intermediate harmful health outcomes (left ventricular hypertrophy, nephropathy, and retinopathy) in persons with normal BP and persons with sustained HTN. Therefore, WCH may not necessarily be a benign condition. Patients with WCH should be identified for close monitoring and instituting lifestyle improvements early, where necessary. Additional research is needed to better define WCH and low-risk patients. Insufficient evidence exists to support other routine uses of ABPM in persons with HTN. Policy updates: 5

6 AmeriHealth Caritas identified one additional systematic review for the United States Preventive Services Task Force (USPSTF) that updated a 2007 systematic review on the benefits and harms of screening for HTN in adults and summarized evidence on rescreening intervals and diagnostic and predictive accuracy for cardiovascular events of different BP methods (Piper, 2015). The USPSTF and CHEP now recommend using ABPM to confirm initially elevated BP measured by office-based screening methods to avoid potential overdiagnosis of isolated clinic HTN and harms of unnecessary treatment (Siu, 2015; Cloutier, 2015). These results do not change earlier findings; therefore, no changes to the current policy are warranted. Current guidelines acknowledge the diagnostic superiority of 24-hour ABPM for its ability to identify sustained HTN by excluding WCH, identifying the presence of episodic or masked HTN, and providing additional prognostic information from nocturnal patterns of BP (O Brien, 2016; Flynn, 2014). Given the known risks associated with inadequately controlled HTN, ABPM may be beneficial when longer measurement periods are needed to diagnose HTN phenotypes to determine an appropriate diagnosis, and the information from ABPM would alter care management. There remains a lack of consensus on the best method for identifying individuals who would most likely benefit from ABPM screening for conditions other than WHC. The use of ABPM for diagnosing masked HTN warrants further consideration, as a significant portion of untreated and treated persons with non-elevated clinic BP have masked HTN and abnormal nocturnal BP profiles (Thomas, 2017; Wang, 2017). Masked HTN and nocturnal BP fall patterns are associated with significantly higher risk of cardiovascular events (Ohkubo, 2005; Salles, 2016). Nocturnal HTN and nondipping may be early markers of masked HTN (Franklin, 2016; O Brien, 2016). Several indices have been developed to identify candidates for ABPM who have normal office BP, but they require further validation before routine clinical use (Booth, 2016; Sheppard, 2016; Schwartz, 2016). Current evidence suggests that masked HTN and MUCH are more likely in individuals of African descent, with increased cardiovascular risk and disease states (e.g., diabetes, chronic renal failure, and metabolic syndrome), older persons, males, shortened sleep time, and obstructive sleep apnea (Colantonio, 2017; Thomas, 2017; Wang, 2017; Franklin, 2016). Persons with prehypertension are more likely to have masked HTN than those with optimal BP and frequently develop target organ damage prior to transitioning to sustained HTN (Franklin, 2016; Colantonio, 2017). It is reasonable to apply ABPM to individuals with normal or prehypertensive casual measurements when there is a clinical suspicion of HTN (e.g., presence of left ventricular hypertrophy) to minimize misclassification of such individuals as normotensive or with controlled HTN. Summary of clinical evidence: Citation Colantonio (2017), Thomas (2017), and Bromfield (2016) for the Content, Methods, Recommendations Exclusively African-American cohort (5,306 total men and women) 20 years and older recruited between 2000 and 2004 from the Jackson, Mississippi, metropolitan area. 6

7 Citation Jackson Heart Study O Brien (2016) ABPM for drug treatment management Cloutier (2015) Diagnosing HTN in Canada Siu (2015) for the USPSTF Screening for HTN in adults Piper (2015) for AHRQ Screening for high BP in adults, Content, Methods, Recommendations Prevalence of daytime HTN > clinic HTN for those not taking antihypertensives (31.8% versus 14.3%) and taking antihypertensives (43.0% versus 23.1%). Percentage of participants not taking and taking antihypertensives with nocturnal HTN (49.4% and 61.7%, respectively), WCH (30.2% and 29.3%, respectively), masked HTN (25.4% and 34.6%, respectively), and non-dipping BP pattern (62.4% and 69.6%, respectively). No association between metabolic syndrome and masked HTN among participants not taking antihypertensives with SBP/DBP /85-89 and <130/85 mm Hg, separately, or among participants taking antihypertensives (n=393). Clinic SBP/DBP /85-89 mm Hg was associated with masked HTN (prevalence ratio, 1.90; 95% confidence interval, 1.56 to 2.32), but not other metabolic syndrome components (abdominal obesity, impaired glucose, low high-density lipoprotein cholesterol, high triglycerides). Masked daytime HTN (defined as mean clinic SBP/DBP < 140/90 mm Hg and mean daytime SBP/DBP 135/85 mm Hg) was less prevalent among participants with better overall cardiovascular health (ideal levels of physical activity, diet, cigarette smoking, and clinic BP). Evidence review and summary of three international guidelines: USPSTF (Sui, 2015); NICE (2011); European Society of Hypertension (O Brien, 2013). Current guidelines emphasize diagnostic superiority of ABPM to identify WCH and masked HTN. ABPM offers diagnostic insights into nocturnal BP patterns and presence of nocturnal HTN. Less emphasis on nocturnal BP patterns in guidelines, but they are relevant in assessing treatment response. Scant recommendations from any guideline on the benefits and use of ABPM for initiating antihypertensives or assessing treatment efficacy. Evidence supports office electronic oscillometric digital BP measurements and out-of-office BP measurements using ABPM or an HBPM diagnostic series to confirm HTN diagnosis (i.e., identify WCH). Recommends screening for HTN in adults ages 18 years and older without known HTN. Recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment. Recommends ABPM as the reference standard for confirming the diagnosis of HTN; HBPM is an alternative if ABPM is not available. Screening intervals: Annually for adults ages 40 years and for those who are at increased risk for HTN. Risk factors for HTN include high-normal BP (130 to 139/85 to 89 mm Hg), overweight or obesity, and African Americans. Every three to five years for adults ages 18 to 39 years with normal BP (< 130/85 mm Hg) who do not have other risk factors. Systematic review of multiple studies, including 11 studies (8,458 total participants) of the predictive value of ABPM methods for long-term cardiovascular events, after adjustment for office-based BP measurement. 7

8 Citation rescreening intervals, and diagnostic/ predictive accuracy of BP methods for cardiovascular events Health Quality Ontario (2012) ABPM versus clinic BP in persons with uncomplicated HTN Health Quality Ontario (2012) Cost-effectiveness analysis (CEA) of conventional BP monitoring versus ABPM Hodgkinson (2011) Content, Methods, Recommendations Overall quality: fair to good. ABPM predicted long-term cardiovascular outcomes independently of office BP (hazard ratio [HR] range, 1.28 to 1.40). Persons with BP in the high-normal range, older persons, those with an above-normal body mass index and African Americans are at higher risk for HTN on rescreening within six years than are persons without these risk factors. For patients who undergo ABPM and have an ambulatory BP < 135/85 mm Hg with no evidence of end-organ damage, their cardiovascular risk is likely similar to that of normotensives. Systematic review of three large RCTs (1,882 total patients) comparing ABPM to clinic BP in persons with uncomplicated HTN. Overall quality: very low to moderate and conflicting. Incorporating ABPM in the diagnostic algorithm for persons with uncomplicated hypertension arterial results in lower and less intensive antihypertensive medication consumption and improved BP control. Over the long term, patients managed with ABPM had fewer fatal and non-fatal cardiovascular events (relative risk [RR] 1.76, 95% confidence interval [CI] 1.03 to 3.02), but conventionally managed patients were more likely to have control of BP (RR 0.90, 95% CI 0.81 to 0.99). No difference between groups in the number of patients who began multi-drug therapy or risk for a drug-related adverse event. A systematic review of two economic evaluations and one primary CEA compared conventional and ambulatory monitoring for uncomplicated HTN. Overall quality: variable. One U.S. study reported savings for diagnosis and treatment with ABPM ranging from $85,000 to $153,000 per 1,000 patients based on 20% and 5% of patients with WCH confirmed to be hypertensive, respectively (Krakoff, 2006). One U.K. study reported incremental cost-effectiveness ratios (ICER) of 3,000 to 26,000 per quality-adjusted life-year (QALY) for ABPM versus conventional monitoring (Lovibond, 2011). Canadian perspective: ABPM would save the health system $19 million (Cdn) over five years, with a borderline dominant effect (ICER: $30 per QALY). Clinical or HBPM versus ABPM in adults Systematic review of 20 eligible studies, of which only seven studies (clinic) and three studies (home) could be directly compared with ABPM. Neither clinic nor HBPM had sufficient sensitivity or specificity to be recommended as a single diagnostic test. ABPM before the start of lifelong drug treatment might lead to more appropriate targeting of treatment, particularly around the diagnostic threshold. CEAs are needed before wholesale changes to the diagnosis of HTN can be recommended. References Professional society guidelines/other: 8

9 Canadian Hypertension Education Program (CHEP). Accurate Measurement of Blood Pressure Hypertension Canada website. Accessed April 14, Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr., et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension Dec; 42(6): Cloutier L, Daskalopoulou SS, Padwal RS, et al. A New Algorithm for the Diagnosis of Hypertension in Canada. Can J Cardiol. 2015; 31(5): Flynn JT, Daniels SR, Hayman LL, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014; 63(5): Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, et al ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J Jul; 34(28): National Institute for Health and Clinical Excellence (NICE). Hypertension. Clinical management of primary hypertension in adults. Clinical guideline 127. Available at: Accessed March 30, O'Brien E, Dolan E. Ambulatory Blood Pressure Monitoring for the Effective Management of Antihypertensive Drug Treatment. Clin Ther. 2016; 38(10): O'Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013; 31(9): Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves JW, Hill MN, et al. Recommendations for blood pressure measurement in humans: an AHA scientific statement from the Council on High Blood Pressure Research Professional and Public Education Subcommittee. J Clin Hypertens (Greenwich) Feb; 7(2): Siu AL. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015; 163(10): Peer-reviewed references: Bloch MJ, Basile JN. UK guidelines call for routine 24-hour ambulatory blood pressure monitoring in all patients to make the diagnosis of hypertension--not ready for prime time in the United States. J Clin Hypertens (Greenwich). 2011; 13(12):

10 Booth JN, 3rd, Muntner P, Diaz KM, et al. Evaluation of Criteria to Detect Masked Hypertension. J Clin Hypertens (Greenwich). 2016; 18(11): Bromfield SG, Shimbo D, Booth JN, 3rd, et al. Cardiovascular Risk Factors and Masked Hypertension: The Jackson Heart Study. Hypertension. 2016; 68(6): Colantonio LD, Anstey DE, Carson AP, et al. Metabolic syndrome and masked hypertension among African Americans: The Jackson Heart Study. J Clin Hypertens (Greenwich) Feb 6. doi: /jch Falkner B. Hypertension in children and adolescents: epidemiology and natural history. Pediatr Nephrol. 2010; 25(7): FDA 510(k) Premarket Notification using product code DXN. FDA website. Accessed March 30, Franklin SS, O'Brien E, Staessen JA. Masked hypertension: understanding its complexity. Eur Heart J Gillespie CD HK. Prevalence of Hypertension and Controlled Hypertension United States, Morbidity and Mortality Weekly Report (MMWR). 2013; 62(3): Hodgkinson J, Mant J, Martin U, et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ. 2011; 342: d3621. Krakoff LR. Cost-effectiveness of ambulatory blood pressure: a reanalysis. Hypertension Jan; 47(1): Lovibond K, Jowett S, Barton P, et al. Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study. Lancet. 2011; 378(9798): Ohkubo T, Kikuya M, Metoki H, et al. Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study. J Am Coll Cardiol. 2005; 46(3): Piper MA, Evans CV, Burda BU, et al. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015; 162(3): Salles GF, Reboldi G, Fagard RH, et al. Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients: The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) Meta- Analysis. Hypertension. 2016; 67(4):

11 Schwartz JE, Burg MM, Shimbo D, et al. Clinic Blood Pressure Underestimates Ambulatory Blood Pressure in an Untreated Employer-Based US Population: Results From the Masked Hypertension Study. Circulation. 2016; 134(23): Sheppard JP, Fletcher B, Gill P, et al. Predictors of the Home-Clinic Blood Pressure Difference: A Systematic Review and Meta-Analysis. Am J Hypertens. 2016; 29(5): The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. NHLBI website. Accessed March 30, Thomas SJ, Booth JN, 3rd, Bromfield SG, et al. Clinic and ambulatory blood pressure in a population-based sample of African Americans: the Jackson Heart Study. J Am Soc Hypertens Feb 16. pii: S (17) doi: /j.jash Twenty-four-hour ambulatory blood pressure monitoring in hypertension: an evidence-based analysis. Ontario Health Technology Assessment Series; 12(15). Health Quality Ontario website. Accessed March 30, Wang YC, Shimbo D, Muntner P, et al. Prevalence of Masked Hypertension Among US Adults With Nonelevated Clinic Blood Pressure. Am J Epidemiol Jan 18. doi: /aje/kww237. What Is High Blood Pressure? NHLBI website. Accessed March 30, CMS National Coverage Determinations (NCDs): Ambulatory Blood Pressure Monitoring. CMS website. Accessed March 30, Local Coverage Determinations (LCDs): No LCDs identified as of the writing of this policy. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. 11

12 CPT Code Description Comment 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. ICD-10 Code Description Comment R03.0 Elevated blood pressure reading without diagnosis of hypertension. HCPCS Level II Code N/A Description Comment 12