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Ambulatory blood pressure monitors (24-hour sphygmomanometers) are portable devices that continually record blood pressure while the patient is involved in daily activities. There are various types of ambulatory monitors; this policy addresses fully automated monitors, which inflate and record blood pressure at pre-programmed intervals.
Ambulatory blood pressure monitoring (ABPM), typically done over a 24-hour period with a fully automated monitor, provides more detailed blood pressure information than readings typically obtained during office visits. The greater number of readings with ABPM ameliorates the variability of single blood pressure measurements and is more representative of the circadian rhythm of blood pressure, compared to the limited number obtained during office measurement.
There are a number of potential applications of ABPM. One of the most common is for evaluation of suspected “white-coat hypertension.” White-coat hypertension is defined as an elevated office blood pressure with normal blood pressure readings outside the physician’s office. The etiology of white-coat hypertension is poorly understood, but may be related to an “alerting" or anxiety reaction associated with visits to the physician's office.
In evaluating patients who have elevated office blood pressure, ABPM is often intended to identify patients with normal ambulatory readings who do not have sustained hypertension. Since 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.
This policy does not directly address other uses of ABPM, including the use of ABPM for the evaluation of ‘masked’ hypertension. Masked hypertension refers to normal blood pressure (BP) readings in the office and elevated BP readings outside of the office. This phenomenon has recently received greater attention, with estimates that up to 10-20% of individuals may exhibit this pattern. Other potential uses of ABPM include monitoring patients with established hypertension under treatment; evaluating refractory or resistant blood pressure; evaluating whether symptoms such as lightheadedness correspond with blood pressure changes; evaluating nighttime blood pressure; examining diurnal patterns of blood pressure; and/or other potential uses.
Many ambulatory blood pressure monitors have received clearance to market through the U.S. Food and Drug Administration (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. The system is only for measurement, recording, and display. It makes no diagnosis."
POLICYAutomated ambulatory blood pressure monitoring over a 24-hour period may be considered medically necessary for patients with elevated office BP, when performed one time to differentiate between ‘white coat hypertension’ and true hypertension, and when the following conditions are met:
All other uses of ambulatory blood pressure monitoring for patients with elevated office BP, including but not limited to repeated testing in patients with persistently elevated office BP, and monitoring of treatment effectiveness, is considered investigational.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
For pediatric patients, the principles of ABPM use to confirm a diagnosis of hypertension are the same as in adults, but there are special considerations as follows:
American Heart Association Classification of Ambulatory BP Levels in Children
Classification Clinic BP Mean Ambulatory BP SBP Loadª <95th percentile <95th percentile <25% >95th percentile <95th percentile <25% <95th percentile >95th percentile >25 >95th percentile <95th percentile 25%-50% >95th percentile >95th percentile 25%-50% >95th percentile >95th percentile >50%
Mean Ambulatory BP
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
8/1999: Reviewed by MPAC; maintained investigational status
2/8/2002: Investigational definition added, Type of Service and Place of Service added
3/12/2002: New 2002 codes added
4/18/2002: Type of Service and Place of Service deleted
5/22/2002: Sources updated
6/4/2002: Code Reference section updated
7/29/2002: Code Reference section revised
11/2002: Reviewed by MPAC; maintained investigational status, Sources updated, ICD-9 procedure code 89.59 added
11/5/2003: Coding reviewed; no changes
11/18/2004: Reviewed by MPAC, remains investigational, Description revised to be consistent with BCBSA policy # 1.01.02
7/19/2005: Code Reference section reviewed, no changes
7/10/2008: Policy reviewed, no changes
03/02/2012: Policy description updated. Policy statement revised to indicate that automated ambulatory blood pressure monitoring over a 24-hour period may be considered medically necessary for patients with elevated office BP, when performed one time to differentiate between ‘white coat hypertension’ and true hypertension, and when the following conditions are met: Office blood pressure elevation is in the mild to moderate range (<180/110), not requiring immediate treatment with medications; and there is an absence of hypertensive end-organ damage on physical examination and laboratory testing. All other uses of ambulatory blood pressure monitoring for patients with elevated office BP remain investigational. FEP verbiage added to the Policy Exceptions section. Code Reference section changed from Non-Covered to Covered. Added 401.0-401.9 and 796.2 to the Covered Codes table. Deleted outdated references from the Sources section.
04/01/2013: Policy reviewed; no changes to policy statement. Removed ICD-9 procedure code 89.59 from the Code Reference section.
03/12/2014: Added "and monitoring of treatment effectiveness" to the investigational policy statement.
02/11/2015: Policy reviewed; description updated. Policy statement unchanged. Policy guidelines updated regarding ABPM use for pediatric patients.
SOURCE(S)Blue Cross & Blue Shield Association policy #1.01.02
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.