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DESCRIPTIONBrain natriuretic peptide (BNP) is a 32-amino acid polypeptide and is classed a cardiac neurohormone that is secreted by the ventricles of the heart in response to volume expansion and pressure overload. The peptide was first isolated from a porcine brain in 1988 and later from the cardiac ventricles of porcine, rat and humans. There are three major natriuretic peptides; atrial natriuretic peptide (ANP), BNP, and C-type natriuretic peptide (CNP) with BNP showing the most promise for diagnostic and prognostic marker of cardiac dysfunction. BNP release appears to be in direct response to ventricular volume stretch and pressure overload. The most widely investigated use for BNP has been in heart failure (HF). Measurement of BNP is a highly sensitive and moderately specific method of differentiating heart failure from other non-cardiac causes of dyspnea. Blood levels of BNP are elevated in heart failure.
CHF is characterized by a progressive activation of the neurohormonal systems that control vasoconstriction and sodium retention; the activation of these systems plays a role in its pathogenesis and progression. As the heart fails, it secretes natriuretic peptides or hormones in response to increasing ventricular and atrial pressure and volume. These naturally occurring peptides assist cardiac function by increasing vasodilation, sodium excretion and diuresis, and by reducing the levels of the neurohormones that cause vasoconstriction, fluid retention, and elevated blood pressure. Atrial natriuretic peptide (ANP) is a vasodilator secreted by the atria in response to atrial wall stress. Brain natriuretic peptide (BNP), also called B-type natriuretic peptide, is a 32-amino-acid natriuretic and vasodilator peptide secreted predominantly from the ventricle in response to pressure overload and expansion. The overall effect of these compensatory mechanisms is increased peripheral resistance, which in turn further reduces left ventricular ejection fraction (LVEF), resulting in a progressive decline in cardiac function. Higher than normal levels of these cardiac neurohormones are found in the peripheral plasma during symptomatic CHF and asymptomatic left ventricular systolic dysfunction (LVSD). A major limitation of standard blood tests for natriuretic peptides in the emergency room or other urgent-care setting has been the protracted length of time needed to obtain results by these techniques.
The Triage® BNP Test, manufactured by Biosite Diagnostics, Inc. (San Diego, CA) is a rapid, point-of-care blood immunoassay to receive clearance from the Food and Drug Administration (FDA) as an aid in the diagnosis of CHF. This in vitro test, which provides results in as few as 15 minutes, is a fluorescence immunoassay that measures BNP levels in anticoagulated whole blood or plasma specimens (approximately 5 mL) obtained by routine venipuncture. The test, which consists of a reaction chamber and a portable meter, is used in conjunction with standard clinical tests to assist the clinician in determining whether or not to refer the patient for further testing or to initiate therapy. The measurable range of the test, in picograms, is from 5 to 1300 pg/mL. While cutoff values for medical decision-making vary among the published clinical trials, the FDA labeling states that the most appropriate cutoff value is 100 pg/mL. In addition to its role in CHF diagnosis, the role of rapid BNP testing for monitoring treatment and predicting the prognosis of patients admitted to the hospital with decompensated heart failure has also been evaluated in preliminary studies. The timely and accurate diagnosis of CHF is critical to health outcomes since effective treatments are available that can slow the inevitable progression to severe heart failure in patients with early-stage disease, improve functional status and symptoms, reduce the need for hospitalization, and prolong survival. The misdiagnosis of an acutely ill patient increases the risk of death or serious complications.
POLICYB-natriuretic peptide may be considered medically necessary for the diagnosis and treatment of congestive heart failure or when performed in the first few days following an acute coronary event for risk stratification.
B-natriuretic peptide is considered investigational when used for routine screening.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
05/01/2013: New policy added. Approved by Medical Policy Advisory Committee.
08/26/2015: Medical policy revised to add ICD-10 codes.
06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
SOURCE(S)Blue Cross Blue Shield of Alabama medical policy, B-Natriuretic Peptide
State of the art: using natriuretic peptide levels in clinical practice. Maisel A, Mueller C, et al. The European Journal of Heart Failure, 2008; 10(9):824-39.
Biomarker-guided therapy in chronic heart failure: A meta-analysis of randomized controlled trials. Felker, G.Michael, et al. American Heart Journal, 2009; 158(3)422-30.
Use of amino-terminal pro-B-type natriuretic peptide to guide outpatient therapy of patients with chronic left ventricular systolic dysfunction. Januzzi JL Jr, Rehman SU, et al. Journal of the American College of Cardiology, 2011; 58(1881-9).
N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study. Moe GW, Howlett J, et al. Circulation. 2007; 115(24) :3103-10.
This 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.