Ambulatory Blood Pressure Monitoring (ABPM) Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 12|01|2016 POLICY LAST UPDATED: 09/04/2024 OVERVIEW 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 pressures (BP) at preprogrammed intervals. Ambulatory blood pressure monitoring (ABPM) has the potential to improve the accuracy of diagnosing hypertension and thus improve the appropriateness of medication treatment. This policy is applicable to Commercial Products only. For Medicare Advantage Plans, see Related Policies section below.
MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION Not applicable
POLICY STATEMENT Commercial Products ABPM over a 24-hour period may be considered medically necessary for individuals with elevated office BP when performed 1 time to differentiate between "white coat hypertension" and true hypertension, and when the following conditions are met: • Office BP elevation is in the mild-to-moderate range (<180/110 mm Hg), 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 ABPM for individuals with elevated office BP are not medically necessary, including but not limited to repeated testing in individuals with persistently elevated office BP and monitoring of treatment effectiveness, as the evidence is insufficient to determine that the technology results in an improvement in the net health outcomes. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not medically necessary benefits/coverage. BACKGROUND Typically done over a 24-hour period with a fully automated device, ABPM provides more detailed BP information than readings typically obtained during office visits. The greater number of readings with ABPM ameliorates the variability of single BP measurements and is more representative of the circadian rhythm of BP.
There are a number of potential applications of ABPM. One of the most common is evaluating suspected “white-coat hypertension” (WCH), which is defined as an elevated office BP with normal blood pressure Medical Coverage Policy | Ambulatory Blood Pressure Monitoring (ABPM)

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

readings outside the physician’s office. The etiology of WCH is poorly understood but may be related to an "alerting" or anxiety reaction associated with visiting the physician's office.

In assessing patients with elevated office BP, 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 BP 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.

For pediatric patients, the principles of ABPM used to confirm a diagnosis of hypertension are the same as in adults, with the following special considerations per 2022 American Heart Association guidelines on ABPM in children and adolescents. A device should be selected that is appropriate for use in pediatric patients, including the use of a cuff size appropriate to the child's size. Threshold levels for the diagnosis of hypertension should be based on pediatric normative data, which use gender-and height-specific values derived from large pediatric populations. The American Heart Association has recommendations and considerations concerning the classification of hypertension in pediatric patients using clinic and ABPM.

Regulatory Status Many ABPMs have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process. As an example of a Food and Drug Administration indication, the Welch Allyn Ambulatory Blood Pressure Monitoring 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."

For individuals with elevated office BP who receive 24-hour automated ABPM, the evidence includes randomized controlled trials, cohort studies, and studies of diagnostic accuracy. Relevant outcomes are test accuracy, other test performance measures, morbid events, and medication use. Data from large prospective cohort studies have established that ABPM correlates more strongly with cardiovascular outcomes than with other methods of BP measurement. Compared directly with other methods, ABPM performed over a 24- hour period has higher sensitivity, specificity, and predictive value for the diagnosis of hypertension than office or home BP measurements. Substantial percentages of patients with elevated office BP have normal BP on ABPM. Prospective cohort studies have reported that patients with white coat hypertension have an intermediate risk of cardiovascular outcomes compared with normotensive and hypertensive patients. The benefit of medication treatment in these patients is uncertain, and they are at risk of overdiagnosis and over treatment based on office BP measurements alone. Use of automated ABPM in these patients will improve outcomes by eliminating unnecessary pharmacologic treatment and avoiding adverse events in patients not expected to benefit. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

CODING Commercial Products The following CPT code(s) are covered when filed with an ICD-10 diagnosis code(s)* listed below: 93784 Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn

continuously for 24 hours or longer; including recording, scanning analysis, interpretation and report 93786 Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn

continuously for 24 hours or longer; recording only 93788 Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn

continuously for 24 hours or longer; scanning analysis with report 93790 Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn

continuously for 24 hours or longer; review with interpretation and report

*ICD-10 Diagnosis Code(s) that may support medical necessity:
I10 I11.0-11.9

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

R03.0
Z01.30-Z01.31

Commercial Products The following HCPCS code(s) is not covered: A4670 Automatic blood pressure monitor

RELATED POLICIES Medicare Advantage Plans National and Local Coverage Determinations

PUBLISHED Provider Update, November 2024 Provider Update, November 2023 Provider Update, December 2022 Provider Update, September 2021

REFERENCES

1. Yang WY, Melgarejo JD, Thijs L, et al. Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes. JAMA. Aug 06 2019; 322(5): 409-420. PMID 31386134
2. Food and Drug Administration (FDA). Welch Allyn ABPM 1600 pre-market notification: 510(k) summary. 2002; https://www.accessdata.fda.gov/cdrh_docs/pdf2/K021756.pdf. Accessed May 16,
4. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). 24-hour ambulatory blood pressure monitoring for the evaluation of patients with elevated office blood pressure. TEC Assessments. 1999;Volume 14:Tab 8.
5. LeFevre F, Aronson N. Technology assessment for ambulatory blood pressure monitoring for adults with elevated office blood pressure decision memo. October 17, 2001; https://www.cms.gov/medicare-coverage-database/details/nca-decision- memo.aspx?NCAId=5&NCDId=254. Accessed May 17, 2024.
6. Imai Y, Hozawa A, Ohkubo T, et al. Predictive values of automated blood pressure measurement: what can we learn from the Japanese population - the Ohasama study. Blood Press Monit. Dec 2001; 6(6): 335-9. PMID 12055412
7. Verdecchia P. Reference values for ambulatory blood pressure and self-measured blood pressure based on prospective outcome data. Blood Press Monit. Dec 2001; 6(6): 323-7. PMID 12055410
8. Head GA, Mihailidou AS, Duggan KA, et al. Definition of ambulatory blood pressure targets for diagnosis and treatment of hypertension in relation to clinic blood pressure: prospective cohort study. BMJ. Apr 14 2010; 340: c1104. PMID 20392760
9. Kikuya M, Hansen TW, Thijs L, et al. Diagnostic thresholds for ambulatory blood pressure monitoring based on 10-year cardiovascular risk. Circulation. Apr 24 2007; 115(16): 2145-52. PMID 17420350
10. Staessen JA, Beilin L, Parati G, et al. Task force IV: Clinical use of ambulatory blood pressure monitoring. Participants of the 1999 Consensus Conference on Ambulatory Blood Pressure Monitoring. Blood Press Monit. Dec 1999; 4(6): 319-31. PMID 10602536
11. Muntner P, Lewis CE, Diaz KM, et al. Racial differences in abnormal ambulatory blood pressure monitoring measures: Results from the Coronary Artery Risk Development in Young Adults (CARDIA) study. Am J Hypertens. May 2015; 28(5): 640-8. PMID 25376639
12. Martin U, Haque MS, Wood S, et al. Ethnicity and differences between clinic and ambulatory blood pressure measurements. Am J Hypertens. Jun 2015; 28(6): 729-38. PMID 25398890
13. Pickering TG, Shimbo D, Haas D. Ambulatory blood-pressure monitoring. N Engl J Med. Jun 01 2006; 354(22): 2368-74. PMID 16738273
14. Staessen JA, Asmar R, De Buyzere M, et al. Task Force II: blood pressure measurement and cardiovascular outcome. Blood Press Monit. Dec 2001; 6(6): 355-70. PMID 12055415

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

14. Hansen TW, Kikuya M, Thijs L, et al. Prognostic superiority of daytime ambulatory over conventional blood pressure in four populations: a meta-analysis of 7,030 individuals. J Hypertens. Aug 2007; 25(8): 1554-64. PMID 17620947
15. Conen D, Bamberg F. Noninvasive 24-h ambulatory blood pressure and cardiovascular disease: a systematic review and meta-analysis. J Hypertens. Jul 2008; 26(7): 1290-9. PMID 18550999
16. 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. Feb 03 2015; 162(3): 192-204. PMID 25531400
17. Panagiotakos D, Antza C, Kotsis V. Ambulatory and home blood pressure monitoring for cardiovascular disease risk evaluation: a systematic review and meta-analysis of prospective cohort studies. J Hypertens. Jan 01 2024; 42(1): 1-9. PMID 37702566
18. 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. Jun 24 2011; 342: d3621. PMID 21705406
19. Stergiou GS, Bliziotis IA. Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review. Am J Hypertens. Feb 2011; 24(2): 123-34. PMID 20940712
20. Stergiou GS, Karpettas N, Panagiotakos DB, et al. Comparison of office, ambulatory and home blood pressure in children and adolescents on the basis of normalcy tables. J Hum Hypertens. Apr 2011; 25(4): 218-23. PMID 20520632
21. Urbina E, Alpert B, Flynn J, et al. Ambulatory blood pressure monitoring in children and adolescents: recommendations for standard assessment: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the council on cardiovascular disease in the young and the council for high blood pressure research. Hypertension. Sep 2008; 52(3): 433-51. PMID 18678786
22. Valent-Morić B, Zigman T, Zaja-Franulović O, et al. The importance of ambulatory blood pressure monitoring in children and adolescents. Acta Clin Croat. Mar 2012; 51(1): 59-64. PMID 22920003
23. Sorof JM, Portman RJ. White coat hypertension in children with elevated casual blood pressure. J Pediatr. Oct 2000; 137(4): 493-7. PMID 11035827
24. Matsuoka S, Kawamura K, Honda M, et al. White coat effect and white coat hypertension in pediatric patients. Pediatr Nephrol. Nov 2002; 17(11): 950-3. PMID 12432440
25. National High Blood Pressure Education Program (NHBPEP). Working Group Report on Ambulatory Blood Pressure Monitoring (NIH Publication No. 92-3028). Bethesda, MD: Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute; 1992.
26. Fagard RH, Staessen JA, Thijs L, et al. Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Circulation. Sep 05 2000; 102(10): 1139-44. PMID 10973843
27. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. Sep 2017; 140(3). PMID 28827377
28. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. May 15 2018; 71(19): 2199-2269. PMID 29146533
29. 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. May 2014; 63(5): 1116-35. PMID 24591341
30. Flynn JT, Urbina EM, Brady TM, et al. Ambulatory Blood Pressure Monitoring in Children and Adolescents: 2022 Update: A Scientific Statement From the American Heart Association. Hypertension. Jul 2022; 79(7): e114-e124. PMID 35603599

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

31. Muntner P, Shimbo D, Carey RM, et al. Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association. Hypertension. May 2019; 73(5): e35-e66. PMID 30827125
32. National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management [NG136]. 2019; https://www.nice.org.uk/guidance/ng136. Accessed May 17, 2024.
33. U.S. Preventive Services Task Force. Screening for Hypertension in Adults. 2021; https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults- screening. Accessed May 15, 2024.
34. Siu AL. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. Nov 17 2015; 163(10): 778-86. PMID 26458123
35. Krist AH, Davidson KW, Mangione CM, et al. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. Apr 27 2021; 325(16): 1650-
36. PMID 33904861
37. U.S. Preventive Services Task Force. High Blood Pressure in Children and Adolescents: Screening. 2020; https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/blood-pressure-in- children-and-adolescents-hypertension-screening. Accessed May 16, 2024.
38. Gartlehner G, Vander Schaaf EB, Orr C, et al. Screening for Hypertension in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. Nov 10 2020; 324(18): 1884-1895. PMID 33170247

39. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring [20.19]. 2019; https://www.cms.gov/medicare-coverage- database/details/ncd-details.aspx?ncdid=254. Accessed May 17, 2024.

    i

    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS