Humana Commercial Clinical Policy

Humana Continuous Ambulatory Blood Pressure Monitoring Form

Effective Date

08/24/2023

Last Reviewed

NA

Original Document

  Reference



Description

Continuous ambulatory blood pressure (CABP) monitoring (also known as ambulatory blood pressure monitoring [ABPM]) is a method of measuring blood pressure (BP) over a specified period of time. CABP monitoring evaluates an individual who is suspected of having white coat hypertension (WCH) (elevated BP only in a healthcare provider’s office or clinic setting) or to confirm hypertension (HTN) with no prior history. Monitoring is generally performed for a minimum of 24 hours up to a maximum of 3 days.

A fully or semi-automated blood pressure device consists of a portable battery-operated monitor worn on the hip and connected to an arm cuff that inflates at preset intervals (usually every 15 to 30 minutes during the day and every 30 to 60 minutes at night). The BP is then measured and recorded in the monitor where it can be retrieved and interpreted by a healthcare provider.

In addition to the automatic preset readings, the semi-automated monitor can also be activated to take additional readings during exertion or when experiencing symptoms such as dizziness or racing heart.

The US Food & Drug Administration (FDA) has approved devices that are purported to use biosensor technology for CABP monitoring. Watch-like wrist devices are cuffless noninvasive blood pressure monitors using either photoplethysmography (PPG) (eg, Biobeat) or oscillometry (eg, HeartGuide) to take BP readings. These devices are available over-the-counter (OTC) without a prescription. (Refer to Coverage Limitations section)

CABP monitoring has been proposed for use in evaluating hypotension and the effectiveness of medication. It also purportedly predicts cardiovascular morbidity or mortality related to left ventricular hypertrophy and may provide useful information regarding BP in the individual with chronic kidney disease, diabetes or preeclampsia. Further, the potential for CABP to capture the absence of dipping (nocturnal decrease of BP) is under investigation to aid in identifying elevated cardiovascular risk. (Refer to Coverage Limitations section)

Coverage Determination

CONTINUOUS AMBULATORY BLOOD PRESSURE MONITORING
Adult (18 Years of Age or Older)

Humana members may be eligible under the Plan for CABP monitoring when the following criteria are met:

  • Monitoring should be performed for at least 24 hours, up to a maximum of 3 days; AND
  • Results are interpreted by a licensed healthcare provider; AND EITHER of the following:
  • Confirm elevated office BP readings without known hypertension; OR
  • Suspected white coat hypertension (WCH) as defined by ALL of the following:
  • Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
  • Office BP reading of 130/80 mmHg or greater on at least 3 separate healthcare provider office visits with two separate measurements taken at each visit; AND
  • At least 2 documented separate BP measurement readings taken outside of the healthcare provider's office which are less than 130/80 mmHg; AND
  • No evidence of end-organ damage (e.g., acute coronary syndrome, acute kidney injury, aortic dissection, hypertensive encephalopathy, pulmonary edema, stroke)
Pediatric (17 Years of Age or Younger)

Humana members may be eligible under the Plan for CABP monitoring when the following criteria are met:

  • Monitoring should be performed for at least 24 hours, up to a maximum of 3 days; AND
  • Results are interpreted by a licensed healthcare provider; AND with ANY of the following:
  • Ambulatory HTN as defined by either of the following:
  1. 12 years of age or younger:
    • BP greater than or equal to 95th percentile in the office or clinic setting (please refer to the American Academy of Pediatrics normative blood pressure tables); AND EITHER of the following:
    • BP greater than 95th percentile outside the office or clinic setting (please refer to the American Academy of Pediatrics normative blood pressure tables); OR
    • Mean ambulatory BP within adolescent cut points*; OR
  2. 13 to 17 years of age:
    • BP greater than 120/80 mmHg in the office or clinic setting; AND
    • Mean ambulatory BP within adolescent cut points*; OR
  • Elevated office BP measurements for 1 year or more as defined by either of the following:
  1. 1 to 12 years of age:
    • BP reading in the office or clinic setting that is the lower of either: 120/80 mmHg to less than 95th percentile (please refer to the American Academy of Pediatrics normative blood pressure tables); OR
    • Greater than or equal to 90th percentile to less than 95th percentile (please refer to the American Academy of Pediatrics normative blood pressure tables); OR
  2. 13 to 17 years of age:
    • Systolic blood pressure (SBP) 120-129 mmHg and diastolic blood pressure (DBP) less than 80 mmHg; OR
  3. Known WCH as defined by either of the following:
  1. 12 years of age or younger:
    • BP greater than or equal to 95th percentile in the office or clinic setting (please refer to the American Academy of Pediatrics normative blood pressure tables); AND EITHER of the following:

Continuous Ambulatory Blood Pressure Monitoring Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0362-022 Page: 4 of 11

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • BP less than 95th percentile outside the office or clinical setting (please refer to the American Academy of Pediatrics normative blood pressure tables); OR
  • Mean ambulatory BP within adolescent cut points*
  1. 13 to 17 years of age:
    • BP greater than or equal to 130/80 mmHg in office or clinical setting; AND
    • Mean ambulatory BP adolescent cut points*; OR
  2. Suspected WCH with the presence of both of the following:
    • Mean SBP and DBP less than 95th percentile (please refer to the American Academy of Pediatrics normative blood pressure tables); AND
    • SBP and DBP load less than 25%; OR
  3. High-risk conditions including, but not limited to, one or more of the following:
    • Chronic kidney disease or structural renal abnormalities
    • Diabetes mellitus (type I or II); OR
    • Genetic syndromes associated with HTN (eg, neurofibromatosis, Turner syndrome, Williams syndrome); OR
    • History of kidney or heart transplant; OR
    • Hypertension currently treated (eg, medication); OR
    • Obesity; OR
    • Obstructive sleep apnea (OSA); OR
    • Repaired aortic coarctation; OR
  4. Secondary hypertension; OR

*Adolescent cut points include mean ambulatory blood pressure measurements for 24-hour (less than 125/75 mmHg), wake (less than 130/80 mmHg) and sleep (less than 110/65 mmHg).

CABP monitoring is generally considered medically necessary no more frequently than once in a six month time period.

Note: The criteria for CABP monitoring are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for CABP monitoring for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for over-the-counter CABP monitoring technologies (eg, Biobeat, HeartGuide) for any indication. Over-the-counter (OTC) items, whether prescribed or unprescribed are generally excluded by certificate. In the absence of a certificate exclusion, OTC items are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Additional information about blood pressure and hypertension may be found from the following websites:

  • American Heart Association
  • National Heart, Lung, and Blood Institute
  • National Library of Medicine

Alternatives to CABP monitoring include, but may not be limited to, the following:

Medical Alternatives
  • Monitoring BP at health care provider office
  • Self-monitoring of BP at home

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Do not rely on the accuracy and inclusion of specific

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

CPT® Code(s)
  • 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
  • 93790 longer; scanning analysis report Ambulatory blood pressure monitoring, utilizing report- generating software, automated, worn continuously for 24 hours or longer; review with interpretation and report
CPT® Category Ill Code(s)

No code(s) identified

HCPCS Code(s)

No code(s) identified

Continuous Ambulatory Blood Pressure Monitoring Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0362-022 Page: 8 of 11

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References
  1. American Academy of Pediatrics (AAP). Clinical practice guideline for screening and management of high blood pressure in children and adolescents. https://www.aap.org. Published September 2017. Accessed July 27, 2023.
  2. American Academy of Pediatrics (AAP). Diagnosis, evaluation and management of high blood pressure in children and adolescents. https://www.aap.org. Published September 2018. Accessed July 27, 2023.
  3. American Association of Clinical Endocrinologists (AACE). American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. https://www.aace.com. Published July 2016. Accessed July 28, 2023.
  4. American Association of Clinical Endocrinologists (AACE). Clinical practice guideline: developing a diabetes mellitus comprehensive care plan – 2022 update. https://www.aace.com. Published October 2022. Accessed July 28, 2023.
  5. American College of Cardiology (ACC). 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. https://www.acc.org. Published November 13, 2017. Accessed July 27, 2023.
  6. American College of Cardiology (ACC). 2019 AHA/ACC clinical performance and quality measures for adults with high blood pressure. https://www.acc.org. Published November 26, 2019. Accessed July 27, 2023.
  7. American College of Cardiology (ACC). 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease. https://www.acc.org. Published July 20, 2023. Accessed August 4, 2023.
  8. American Diabetes Association (ADA). Position Statement. Diabetes and hypertension. https://www.diabetes.org. Published September 2017. Accessed July 27, 2023.
  1. American Diabetes Association (ADA). Standards of Medical Care in Diabetes – 2023. Cardiovascular disease and risk management. https://www.diabetes.org. Published January 2023. Accessed July 28, 2023.
  2. American Heart Association (AHA). Scientific Statement. Ambulatory blood pressure monitoring in children and adolescents: 2022 update. https://www.heart.org. Published May 23, 2022. Accessed July 28, 2023.
  3. American Heart Association (AHA). Scientific Statement. Measurement of blood pressure in humans. https://www.heart.org. Published May 2019. Accessed July 28, 2023.
  4. American Heart Association (AHA). Scientific Statement. Pediatric primary hypertension: an underreported condition. https://www.heart.org. Published June 2023. Accessed July 27, 2023.
  5. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). Ambulatory blood pressure monitoring (20.19). https://www.cms.gov. Published July 1, 2003. Updated July 2, 2019. Accessed July 27, 2023.
  6. ClinicalKey. Clinical Overview. Hypertension. https://www.clinicalkey.com. Updated April 3, 2023. Accessed July 17, 2023.
  7. ECRI Institute. Hotline Response (ARCHIVED). Continuous ambulatory blood pressure monitoring for diagnosing hypertension. https://www.ecri.org. Published August 13, 2004. Updated September 26, 2013. Accessed July 16, 2023.
  8. Endocrine Society. Clinical Practice Guideline. Primary prevention of ASCVD and T2DM in patients at metabolic risk. https://www.endocrine.org. Published July 31, 2019. Accessed July 27, 2023.
  9. Hayes, Inc. Medical Technology Directory (ARCHIVED). Ambulatory blood pressure monitoring with fully automatic portable monitors. https://evidence.hayesinc.com. Published December 4, 2004. Updated November 19, 2008. Accessed July 16, 2023.
  10. MCG Health. Ambulatory blood pressure monitoring, 24-hour. 27th edition. https://www.mcg.com. Accessed July 17, 2023.
  11. National Heart, Lung and Blood Institute (NHLBI). The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. https://www.nhlbi.nih.gov. Published May 2005. Accessed July 28, 2023.
  12. UpToDate, Inc. Ambulatory blood pressure monitoring in children. https://www.uptodate.com. Updated June 2023. Accessed July 17, 2023.
  13. UpToDate, Inc. Blood pressure measurement in the diagnosis and management of hypertension in adults. https://www.uptodate.com. Updated June 14, 2023. Accessed July 17, 2023.
  14. UpToDate, Inc. Chronic kidney disease in children: overview of management. https://www.uptodate.com. Updated July 2023. Accessed July 17, 2023.
  15. UpToDate, Inc. Definition and diagnosis of hypertension in children and adolescents. https://www.uptodate.com. Updated June 2023. Accessed July 17, 2023.
  16. UpToDate, Inc. Definition, risk factors, and evaluation of resistant hypertension. https://www.uptodate.com. Updated June 2023. Accessed July 17, 2023.
  17. UpToDate, Inc. Evaluation and diagnosis of hypertension in infants between one month and one year of age. https://www.uptodate.com. Updated June 2023. Accessed July 17, 2023.
  18. UpToDate, Inc. Hypertension in dialysis patients. https://www.uptodate.com. Updated June 2023. Accessed July 17, 2023.
  19. UpToDate, Inc. Out-of-office blood pressure measurement: ambulatory and self-measured blood pressure monitoring.https://www.uptodate.com. Updated June 2023. Accessed July 27, 2023.

Accessed July 17, 2023. Continuous Ambulatory Blood Pressure Monitoring Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0362-022 Page: 11 of 11

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. UpToDate, Inc. Overview of hypertension in adults. https://www.uptodate.com. Updated June 2023. Accessed July 17, 2023.
  2. UpToDate, Inc. Toxicity of molecularly targeted antiangiogenic agents: cardiovascular effects. https://www.uptodate.com. Updated June 2023. Accessed July 17, 2023.
  3. UpToDate, Inc. White coat and masked hypertension. https://www.uptodate.com. Updated June 2023. Accessed July 17, 2023.
  4. US Department of Veterans Affairs (VA). VA/DoD Clinical Practice Guideline. The diagnosis and management of hypertension in the primary care setting. https://www.va.gov. Published March 2020. Accessed July 27, 2023.
  5. US Preventive Services Task Force (USPSTF). Recommendation Statement. Screening for high blood pressure in children and adolescents. https://www.uspreventiveservicestaskforce.org. Published November 10, 2020. Accessed July 27, 2023.
  6. US Preventive Services Task Force (USPSTF). Recommendation Statement. Screening for hypertension in adults. https://www.uspreventiveservicestaskforce.org. Published April 27, 2021. Accessed July 27, 2023.