HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
M-70-017
Topic:
Ambulatory Blood Pressure Monitoring
Section:
Diagnostic Medical
Effective Date:
August 23, 2021
Issued Date:
August 23, 2021
Last Revision Date:
July 2021
Annual Review:
July 2021
 
 

Ambulatory blood pressure monitoring is typically done over a 24-hour period with a fully automated monitor. This provides more detailed blood pressure information than a traditional reading 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 an office measurement.

Policy Position

Adults

ABPM may be considered medically necessary for ANY of the following indications:

  • Suspected white coat hypertension (WCH) with no evidence of end-organ damage;
    • The physician has performed at least three blood pressure measurements at least one(1) week apart in the office; and
    • Blood pressure measurements by non-physicians (e.g., nurse, technician) in the office have been done and stage one hypertension readings have been obtained but less than 180/110, not requiring immediate treatment with medications;  and
    • Member has repeated blood pressure measurements at home over at least one (1) month, and the diagnosis of hypertension remains in question: or
  • Resistant hypertension in individuals who are being treated with three (3) or more medications: or
  • Hypertensive individuals with hypotensive symptoms thought to be related to antihypertensive medications or neurological symptoms: or
  • For individuals whose symptomatology (paroxysms of excessive sweating, palpitations, apprehension) suggest episodic hypertension secondary to an adrenal tumor and office blood pressure measurements are repeated normal: or
  • For evaluation of syncope or near syncope when used in conjunction with a 24 hour Holter monitor to determine whether symptoms are the direct result of an arrhythmia: or
  • To investigate blood pressure changes in individuals with nocturnal angina. 

ABPM not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

 

Note: See table below

93784

93786

93788

93790

 

 

 


Children/Adolescents

ABPM in children/adolescents greater than or equal to age five (5) may be considered medically necessary in ANY of the following settings:

  • Confirming the diagnosis of hypertension including differentiating true hypertension from WCH:
    • When office blood pressure measurements are in the elevated blood pressure category for one (1) year or more; or
    • When blood pressure measurements fall within the Stage 1 HTN category over three (3) clinic visits at least one (1) to two (2) weeks apart; or
    • When blood pressure measurements fall within the Stage 2 HTN category twice within one (1) week; or
  • Assessing symptoms related to suspected drug-related hypotension; or
  • Drug resistant hypertension, or
  • To assess effectiveness of hypertensive treatment, or
  • Children and adolescents with ANY of the following:
    • A history of aortic coarctation, or
    • A history of low birth weight, or
    • Chronic Kidney Disease (CKD) and structural renal abnormalities, or
    • Endocrine disorders associated with hypertension (e.g. Congenital adrenal hyperplasia, familial hyperaldosteronism, etc.), or 
    • Genetic syndromes associated with hypertension (e.g. neurofibromatosis, Turner syndrome, Williams syndrome, sickle cell disease, etc.), or
    • Obesity, or
    • Sleep-Disordered Breathing (SDP), or
    • Type 1 Diabetes Mellitus (T1DM), or
    • Type 2 Diabetes Mellitus (T2DM).

ABPM in children and adolescents should be used by experts in the field of pediatric nephrology and pediatric cardiology who are experienced in its use and interpretation.

ABPM not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

 

Note: See table Below

93784

93786

93788

93790

 

 

 


Non-invasive assessment of central blood pressure (e.g., SphygmoCor System) is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

93050

 

 

 

 

 

 


Adults

BP Classification

Systolic BP, mm Hg*

 

Diastolic BP, mm Hg*

Normal

<120

and

<80

Prehypertension

120-129

and

<80

Stage 1 Hypertension

130-139

or

80-89

Stage 2 Hypertension

>140

or

>90


Children

For Children aged one (1)- < 13 Years of Age

For Children Aged ≥13 Years of Age

Normal BP: <90th percentile

Normal BP: <120/<80 mm Hg

Elevated BP: ≥90th percentile to <95th percentile or 120/80mm Hg to <95th percentile (whichever is lower)

Elevated BP: 120/<80 to 129/<80 mm Hg

Stage 1 HTN: ≥95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mm Hg (whichever is lower)

Stage 1 HTN: 130/80 to 139/89 mm Hg

Stage 2 HTN: ≥95th percentile + 12 mm Hg, or ≥140/90 mm Hg (whichever is lower)

Stage 2 HTN: ≥140/90 mm Hg
Professional Statements and Societal Positions Guidelines

American Academy of Pediatrics-2017

The American Academy of Pediatrics published clinical guidelines for the screening and management of high blood pressure (BP) in children and adolescents.27, Table below lists recommendations made.

Table:

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


American College of Cardiology et al-2017

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. Table below lists recommendations made.

Table:

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


Diagnosis Codes

Covered diagnosis codes for Procedure Codes: 93784, 93786, 93788, and 93790

C74.00

C74.01

C74.02

D44.7

D57.00

D57.01

D57.02

D57.1

D57.20

D57.211

D57.212

D57.219

D57.3

D57.40

D57.411

D57.412

D57.419

D57.80

D57.811

D57.812

D57.819

E05.00

E05.01

E05.10

E05.11

E05.20

E05.21

E05.30

E05.31

E05.40

E05.41

E05.80

E05.81

E05.90

E05.91

E10.9

E11.9

E21.0

E21.1

E21.2

E21.3

E21.4

E21.5

E24.0

E24.8

E24.9

E26.01

E26.02

E26.09

E66.8

E66.9

F84.3

G47.30

G47.31

G47.32

G47.33

G47.34

G47.35

G47.36

G47.37

G47.39

I10

I11.9

I15.0

I15.1

I15.2

I15.8

I15.9

I20.8

I95.0

I95.1

I95.2

I95.3

I95.81

I95.89

I95.9

N18.1

N18.2

N18.4

N18.5

N18.6

N18.9

N18.30

N18.31

N18.32

N26.2

Q78.1

Q85.00

Q85.01

Q85.02

Q85.03

Q85.09

Q93.82

Q96.0

Q96.1

Q96.2

Q96.3

Q96.4

Q96.8

Q96.9

R03.0

R55

      


Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

ABPM is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.