Download Automated Ambulatory Blood Pressure Monitoring For The

MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
Original Issue Date (Created):
7/1/2002
Most Recent Review Date (Revised):
7/26/2016
Effective Date:
1/1/2017
POLICY
RATIONALE
DISCLAIMER
POLICY HISTORY
PRODUCT VARIATIONS
DEFINITIONS
CODING INFORMATION
DESCRIPTION/BACKGROUND
BENEFIT VARIATIONS
REFERENCES
I. POLICY
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;
• 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,
including but not limited to repeated testing in patients with persistently elevated office BP, is
considered investigational, as there is insufficient evidence to support a conclusion concerning
the health outcomes or benefits associated with this procedure.
Policy Guidelines
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 1:



A device should be selected that is appropriate for use in pediatric patients, including 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.
Recommendations from AHA guidelines concerning classification of hypertension in
pediatric patients using clinic and ambulatory BP are given in the following table:
Page 1
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
Table 1. Americ an Heart Association Classification of Ambulatory BP Levels in Children 1
Classificatiion
Clinic BP
Mean Ambulatory SBP
SBP Load"
Normal BP
<95th percentile
<95th percentile
WC HTN
>95th percentile
<95th percentile
Masked HTN
<95th percentile
>95th percentile
Pre-HTN
>95th percentile
<95th percentile
Ambulatory HTN
>95th percentile
>95th percentile
Severe Ambulatory HTN
>95th percentile
>95th percentile
BP: blood pressure; HTN hypertension; SBP systolic blood pressure; WC: white coat
3
Percent of SBP readings that are above 95th percentile for gender and height
<25%
<25%
>25
25%-50%
25%-50%
>50%
Cross-reference:
MP-6.026 Durable Medical Equipment
II. PRODUCT VARIATIONS
TOP
This policy is applicable to all programs and products administered by Capital BlueCross unless
otherwise indicated below.
BlueJourney HMO*
BlueJourney PPO*
FEP PPO**
* Refer to Centers for Medicare and Medicaid (CMS) National Coverage Determination (NCD)
20.19. Ambulatory Blood Pressure Monitoring.
** Refer to FEP Medical Policy Manual MP-1.01.02, Automated Ambulatory Blood Pressure
Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure. The
FEP Medical Policy Manual can be found at: www.fepblue.org
III. DESCRIPTION/BACKGROUND
TOP
Ambulatory blood pressure monitors (24-hour sphygmomanometers) are portable devices
recording 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 typically
obtained during office visits. The greater number of readings with ABPM ameliorates the
Page 2
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
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 evaluating
suspected “white-coat hypertension” (WCH), which is defined as an elevated office blood
pressure with normal blood pressure 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 evaluating patients having 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 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.” 2
IV. RATIONALE
TOP
The most recent update with literature review covered the period through December 2, 2014.
The evidence base for this policy originates from a 1999 TEC Assessment3 and subsequent reanalysis of this report conducted for the Centers for Medicare and Medicaid Services in 2001.4
The focus is on the use of ambulatory blood pressure monitoring (ABPM) in previously
untreated patients with elevated office blood pressure (BP). In this situation, ABPM is primarily
intended to evaluate “white coat hypertension” (WCH), or “isolated clinic hypertension.” This
entity is defined as an elevated office BP with normal BP readings outside the physician’s office.
Page 3
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
It is diagnosed by obtaining multiple out-of-office BP measurements and comparing them with
office readings.
Evidence on whether ABPM improves health outcomes for patients with elevated office BP will
be summarized in 3 general areas of research:
1. Reference values for ABPM
2. Impact of ABPM on outcomes
a. Clinical trials
b. Prospective cohort studies
3. Accuracy of ABPM as a diagnostic test for hypertension
c. Prospective cohort studies
d. Cross-sectional studies
Reference Values for ABPM Monitoring
One important area addresses the question of reference values for ABPM to provide guidelines
for “normal” and “abnormal” ABPM readings.5,6 Studies that have compared ABPM
measurements with office measurement consistently reveal lower values for ABPM. Therefore, it
is not possible to use reference values for office BP to evaluate the results of ABPM.
Reference values for ABPM have been derived by several methods: (1) estimates of populationbased ABPM results to define the range and distribution of ABPM values; (2) direct comparisons
of average ABPM values and office BP to determine the level of ABPM that corresponds to an
office BP of 140/90; and (3) correlations of ABPM results with cardiovascular outcomes to
determine ABPM levels at which the risk for cardiovascular events increases, or is similar to the
risk associated with an office BP of 140/90.7,8
Although specific recommendations vary slightly, current thresholds for defining a normal
ABPM are 24- hour average BP of 130/80 and daytime average BP of 135/85. An ABPM
Consensus Conference task force on ABPM considered data on the statistical distribution of
ABPM, correlation with office BP, and correlation with cardiovascular outcomes in deriving
recommendations for reference values for ABPM.9 Their recommendations are summarized in
Table 2. Subsequent studies have identified racial and ethnic variation in ABPM results,10 but
impacts of these differences on clinical management may be minimal.11
Table 2. ABPM Consensus Conference Task Force IV: Adult ABPM Thresholds 9
ABPM Measure
95th Percentile
24-hour average
132/82
Daytime average
138/87
Nighttime average
123/74
ABPM: ambulatory blood pressure monitoring.
Normotension
~1 30/80
~1 35/85
~1 20/70
Hypertension
>135/85
>140/90
>125/75
Page 4
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
Section Summary
Reference values for normal and abnormal ABPM results have been derived from epidemiologic
research. These reference values vary slightly among different sources but are available for
clinical use.
Impact of ABPM on Outcomes
Clinical Trials
Direct evidence of the efficacy of ABPM for improving outcomes in this setting would be
obtained from randomized controlled trials (RCTs) comparing outcomes of (1) patients
diagnosed and treated based on conventional BP measurements alone with (2) patients
additionally undergoing ABPM used to guide therapy (e.g., withholding or randomizing
treatment among those with WCH). This notion parallels the statement from the U.S. National
High Blood Pressure Education Program Working Group on Ambulatory Blood Pressure
Monitoring in 1992, “Ideally, de novo longitudinal studies should be undertaken to determine
which ambulatory profiles are associated with increased cardiovascular risk and what
transformations of ambulatory profiles induced by antihypertensive therapy are associated with
reductions in risk.”12 RCTs using ABPM for monitoring treatment response but not to diagnose
hypertension have been conducted. However, a substudy of the Systolic Hypertension in Europe
(Syst-Eur) trial did address this question indirectly.13
The Syst-Eur trial, a large, multicenter RCT, enrolled patients 60 years of age or older with
isolated systolic hypertension and randomized them to antihypertensive treatment or placebo.13 A
substudy evaluated 695 patients (from the total Syst-Eur sample of 4695 patients) who
underwent 24-hour ABPM in addition to the usual study protocol. Conventional BP was defined
from the mean of 6 baseline clinic BPs (2 readings obtained with the patient seated at each of 3
baseline visits at least 1 month apart).
Participants were classified into 3 groups based on ABPM readings: nonsustained hypertension
(ie, WCH), mild-sustained hypertension, and moderate-sustained hypertension. Reduction in
cardiovascular events was compared between active and placebo groups among patients in each
of the 3 categories. For patients with nonsustained hypertension, there was a numerically lower
rate of adverse outcomes in the treated group for stroke (0 vs 2, p=0.16) and cardiovascular
events (2 vs 6, p=0.17), i.e., differences not reaching statistical significance. There was a
significant reduction in events with treatment only among patients with moderate-sustained
hypertension.
Staessen et al (1999) analyzed follow-up data (median follow-up, 4.4 years) from an apparently
overlapping subset of 808 older individuals from the Syst-Eur trial who had isolated systolic
hypertension measured conventionally (i.e., systolic BP [SBP], 160-219 mm Hg; diastolic BP
Page 5
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
[DBP], <95 mm Hg).14 BPs also were measured by ABPM; average SBP and DBP were higher
with conventional measurements (by 21.9 and 1.9 mm Hg, respectively). ABPM was
significantly associated with cardiovascular end points, even when conventional BP was taken
into account.
Prospective Cohort Studies
Well-designed, prospective cohort studies could provide indirect evidence on the potential
benefit of treatment for patients with WCH. Ideally, prospective studies would compare
outcomes of untreated patients with WCH with normotensive and sustained hypertensive patients
(the latter being treated).
Studies should control for important potential confounders such as adequacy of BP control, age,
sex, smoking status, lipid levels, and diabetes. Well-designed and conducted prospective cohort
studies finding that untreated WCH patients have a cardiovascular event risk similar to that of
normotensive patients would imply these patients accrue little treatment benefit. In contrast, if
the cardiovascular risk for patients with WCH is increased, then there is a potential benefit to
treatment.
Numerous large cohort studies have used ABPM to identify patients with WCH and compared
subsequent cardiovascular outcomes in WCH patients, normotensive patients, and sustained
hypertensive patients.15-22 These studies have generally been consistent in reporting that
cardiovascular risk for patients with WCH is intermediate, between that of hypertensive patients
and normotensive patients. For example, a 2014 meta-analysis found that mean left ventricular
mass index and mean left atrial diameter in patients with WCH was intermediate, between that of
hypertensive patients and normotensive individuals.23 A 2013 review found that in patients with
WCH, prevalence of cardiovascular risk factors, such as glucose dysregulation, diabetes,
increased left ventricular mass index, and sustained hypertension, was increased compared with
normotensive individuals, but the risk of cardiovascular events was not.24 The authors attributed
the latter finding to the frequent use of antihypertensive treatment in WCH.
At least 3 meta-analyses have been published that summarize results of the available cohort
studies. Fagard and Cornelissen (2007) summarized data from 7 cohort studies that compared
outcomes in 4 groups of patients: normotensive patients, WCH patients, “masked” hypertensive
patients, and sustained hypertensive patients (total N=11,502).25 Average follow-up in these
studies was 8.0 years. Using normotensive patients as the reference standard, the risk for patients
with WCH was not significantly higher (hazard ratio [HR], 1.12; 95% confidence interval [CI],
0.84 to 1.50). There was an increased risk for patients with “masked” hypertension (HR=2.00;
95% CI, 1.58 to 2.52) and patients with sustained hypertension (HR=2.28; 95% CI, 1.87 to 2.78).
Hansen et al (2007) used patient-level data from 4 previous cohorts of patients to construct an
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MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
international database of ambulatory BP monitoring.26 This database included 7069 patients from
4 cohorts in Europe and Japan that represented population-level patient samples. In this analysis,
there was a trend toward increased cardiovascular events in patients with WCH that did not reach
statistical significance (HR=1.22; 95% CI, 0.96 to 1.53; p=0.09). Statistically increased risks
were found in patients with “masked” hypertension (HR=1.62; 95% CI, 1.35 to 1.96; p<0.001) or
sustained hypertension (HR=1.80; 95% CI, 1.59 to 2.03; p<0.001).
A third pooled analysis by Verdecchia et al (2005) included studies conducted in the United
States, Italy, and Japan.27 This analysis compared short- and long-term stroke risk among 4406
individuals with essential hypertension and 1549 normotensive controls; none were treated at
baseline. WCH was present in 9% of the hypertensive group. During the first 6 years, follow-up
stroke incidence appeared similar among WCH and normotensive groups. However, by 9 years,
stroke incidence among WCH patients reached that of the hypertensive group (measured by
ABPM). At the last telephone contact or clinic visit, similar proportions of those initially
classified as WCH and normotensive were receiving antihypertensive medications from 5
different drug classes. This result suggests WCH may not be entirely benign.
Section Summary
Data from large prospective cohort studies establish that ABPM correlates more strongly with
cardiovascular outcomes compared with other methods of BP measurement, and that WCH, as
defined by ABPM, is associated with an intermediate risk of cardiovascular outcomes compared
with normotensive and hypertensive patients.
Accuracy of ABPM as a Diagnostic Test for Hypertension
Studies of the accuracy of ABPM as a diagnostic test for hypertension are of 2 types. First,
prospective cohort studies that correlate results of ABPM with future cardiovascular events, and
compare this correlation with that of office BP measurements, provide indirect evidence on
ABPM accuracy by assuming that the more accurate test will have a higher correlation with
hypertension-related outcomes. Second, cross-sectional studies can directly compare the
accuracy of ABPM compared with office BP, using a criterion standard for diagnosis. For these
types of studies, ABPM is often considered the criterion standard, and accuracy of other methods
of BP measurement is compared with ABPM.
Prospective Cohort Studies
Many prospective cohort studies have compared ABPM with office BP in predicting
cardiovascular events. Although results of these studies are not entirely consistent, the majority
report that ABPM has greater predictive ability for cardiovascular events compared with office
BP measurement.28,29 A summary of relevant systematic reviews and meta-analyses of these
studies follows.
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MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
Hansen et al (2007) conducted a patient-level meta-analysis using data from four populations in
Belgium, Denmark, Japan, and Sweden (total N=7030).26 Predictive value of ABPM and clinic
BP for fatal and nonfatal cardiovascular events was reported. Both ABPM and office BP were
predictors of outcomes in univariate and partially-adjusted multivariate models. In the fully
adjusted model, ABPM remained a significant predictor of outcomes while office BP did not.
Conen et al (2008) conducted a meta-analysis of 20 cohort studies that evaluated the correlation
between ABPM and outcomes, controlling for office BP in the analysis.30 These authors reported
that ABPM was a strong predictor of cardiovascular outcomes and that controlling for office BP
had little effect on risk estimates. These results support the hypothesis that risk information
obtained from ABPM is independent of that obtained from office BP.
Cross-Sectional Studies
Numerous studies have directly compared ABPM with office BP and/or home self-measured BP.
Hodgkinson et al (2011) performed a systematic review of studies that compared ABPM with
home or office BP and used clearly defined thresholds to determine the accuracy of diagnosis of
hypertension.31 Of 10 studies identified, 7 compared ABPM with office BP measurements, and 3
compared ABPM with home self-measurement. Using a 24-hour ABPM threshold of 135/85,
clinic BP measurements had a sensitivity of 75% (95% CI, 61% to 85%) and a specificity of 75%
(95% CI, 48% to 90%). Home BP self measurement had a sensitivity of 86% (78% to 91%) and
a specificity of 62% (48% to 75%). The accuracy of office and home BP was not considered
adequate for use as a single diagnostic test for hypertension, and it was hypothesized that the use
of office and/or home measurements may lead to substantial overdiagnosis and overtreatment.
In a similar systematic review, Stergiou and Bliziotis (2011) compared the accuracy of ABPM
with home BP measurement for the diagnosis of hypertension.32 A total of 16 studies were
included in this analysis. Sensitivity of home BP measurement, compared with ABPM, ranged
from 36% to 100% with a median value of 74%. Specificity ranged from 44% to 96%, with a
median value of 84%. This study also reported the diagnostic agreement between the 2 methods
of BP measurement, as measured by the statistic. Kappa could be calculated in 11 studies; the
range of scores was 0.37 to 0.73, with a median value of 0.46. This level indicates moderate
agreement between ABPM and home monitoring in the diagnosis of hypertension.
Lovibond et al (2011) performed a cost-effectiveness study comparing ABPM with office BP
measurement and home measurements.33 For most patient indications, ABPM resulted in the
greatest amount of quality-adjusted life years (QALYs) gained, and in individuals older than age
50 years, ABPM was consistently associated with the largest incremental gain in QALYs.
ABPM was cost-saving in all patient groups compared with alternatives and remained the most
cost-effective alternative under the majority of sensitivity analyses. As a result of these findings,
Page 8
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
the authors recommended that ABPM be performed for most patients before the decision to start
anti-hypertensive medications is made.
Other Studies
A number of trials have evaluated ABPM for the management of established hypertension,
comparing the effect of ABPM use on BP control and medication use with usual care based on
office measurements.34-36
Some studies have compared home self-monitoring with ABPM and office measurement for
management of medication treatment.37-39 Others have attempted to determine predictors of
WCH based on clinical factors and office BP readings.40 However, these areas of research do not
provide specific evidence on the use of ABPM for diagnosing and treating patients with elevated
office BP and thus are not included in the final evidence base for this policy.
Section Summary
Studies comparing home BP monitoring and office monitoring with ABPM as the criterion
standard report that the sensitivity and specificity of alternative methods of diagnosing
hypertension are suboptimal.
ABPM in Children and Adolescents
ABPM has been used in children and adolescents for similar purposes as in adults, including use
in children and adolescents with elevated office BP to distinguish true hypertension from WCH.
Evidence on use of ABPM in children and adolescents is of similar type as for adults but of
smaller quantity. A representative sample of studies identified follows.
Normative values for pediatric patients have been established by large population-based studies
of children and adolescents.41 Elevated readings are defined as values greater than the 95th
percentile for sex, age, and height. These studies also have established that patterns of
ambulatory BP in children differ from those in adults. In children, ambulatory BP is generally
higher than the corresponding office BP, in contrast to adult ambulatory BP readings that are on
average lower than office BP. This pattern is more pronounced in younger children, and the
difference progressively declines with age.
Guidelines for classification of hypertension in children and adolescents were published by the
American Heart Association in 2008 (see Policy Guidelines section for specific
recommendations).42
In a study from Europe, 139 children and adolescents between the ages of 4 to 19 years with
elevated office BP were evaluated by ABPM monitoring.43 Thirty-two (23.0%) of 139
participants had WCH, as evidenced by a normal 24-hour ABPM result. Of patients with true
Page 9
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
hypertension, 21 (19.6%) of 107 had evidence of target organ damage, compared with none of
the patients with WCH. In a similar study from the United States, 67 otherwise healthy children
underwent ABPM, 51 of whom had an elevated office BP.44 Using 3 definitions of WCH of
varying BP cutoffs, WCH was identified in 22% to 53% of children with elevated office BP. In a
study from Japan, 206 children and adolescents between the ages of 6 to 25 years underwent
ABPM, 70 of whom had elevated office BP.45 Among the 70 patients with elevated office
BP, 33 (47%) had WCH, as defined by a normal ABPM result. A white coat effect of 10 mm Hg
or more was reported in 50% of patients with office hypertension and 25% of patients with
normal office BP.
Section Summary
Reference values for normal and abnormal ABPM results in children and adolescents have been
derived from epidemiologic research and have been used to differentiate WCH from true
hypertension in pediatric patients.
Ongoing and Unpublished Clinical Trials
An online search of ClinicalTrials.gov identified 1 small RCT, a comparative effectiveness pilot
study of ABPM versus office BP monitoring for diagnosing and managing hypertension
(NCT02121041). Twenty-four untreated patients with office-diagnosed hypertension (clinic
SBP, 126-150 mm Hg) will be randomized to usual care (office BP monitoring) or ABPMguided care. For patients in the ABPM-guided group, treatment decisions will be based on results
of 3 ABPM sessions taken over 4 months. The trial is sponsored by the North Carolina
Translational and Clinical Sciences Institute at the University of North Carolina. Estimated
completion is June 2016.
Summary of Evidence
Ambulatory blood pressure monitoring (ABPM) performed over a 24-hour period is a more
accurate method for evaluating blood pressure (BP) compared with office measurements and
home BP measurements. Reference values for normal and abnormal ABPM results have been
derived from epidemiologic research for both adults and children. These reference values vary
slightly among different sources but are available for clinical use. Data from large prospective
cohort studies establish that ABPM correlates more strongly with cardiovascular outcomes
compared with other methods of BP measurement. Prospective cohort studies also indicate that
white coat hypertension (WCH), as defined by ABPM, is associated with an intermediate risk of
cardiovascular outcomes compared with normotensive and hypertensive patients
Studies comparing home BP monitoring and office monitoring to ABPM as the criterion
standard report that the sensitivity and specificity of alternative methods of diagnosing
hypertension are suboptimal. This is true for both adult and pediatric patients. Substantial
percentages of patients with elevated office BP are found to have normal BP on ABPM, and
Page 10
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
these patients are at risk for overdiagnosis and overtreatment based on office BP measurements
alone. Use of ABPM in these patients will improve outcomes by eliminating the inconvenience
and morbidity of pharmacologic treatment in patients who are not expected to benefit. Therefore,
ABPM may be considered medically necessary for the evaluation of patients with elevated office
BP.
Practice Guidelines and Position Statements
National Institute for Health and Care Excellence
The U.K.’s National Institute for Health and Care Excellence (NICE) issued updated
hypertension guidelines in 2011.46 For diagnosing hypertension, NICE made the following
recommendations concerning ABPM:
 If the clinic BP is 140/90 mm Hg or higher, offer ABPM to confirm the diagnosis of
hypertension
 When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2
measurements per hour are taken during the person’s usual waking hours. Use the
average of at least 14 measurements taken during usual waking hours to confirm a
diagnosis of hypertension.
Canadian Hypertension Education Program
Guidelines for BP measurement, diagnosis, and risk assessment have been published annually by
the Canadian Hypertension Education Program. Strength of evidence underlying
recommendations is graded ranging from “A” (studies with high internal validity, statistical
precision, and generalizability) to “D” (expert opinion).
The 2014 recommendations47 include:
 Ambulatory BP readings can be used in the diagnosis of hypertension (grade C).
 ABPM should be considered when an office-induced increase in BP is suspected in
treated patients with:
o BP that is not below target despite receiving appropriate chronic
antihypertensive therapy (grade C);
o symptoms suggestive of hypotension (grade C); or
o fluctuating office BP readings (grade D).
 Physicians should use only ABPM devices that have been validated independently using
established protocols (grade D).
 Therapy adjustment should be considered in patients with a 24-hour ambulatory SBP
(systolic blood pressure) of ≥130 mm Hg or DBP (diastolic blood pressure) of ≥80 mm
Hg or an awake SBP of ≥135 mm Hg or DBP of ≥85 mm Hg (grade D).
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MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER

MP-6.002
The magnitude of changes in nocturnal BP should be taken into account in any decision
to prescribe or withhold drug therapy based upon ambulatory BP (grade C) because a
decrease in nocturnal BP of less than 10% is associated with increased risk of CV events.
American Heart Association Recommendations for ABPM in Children and Adolescents
The American Heart Association published consensus recommendations in 2008 developed by
their Atherosclerosis, Hypertension, and Obesity in Youth Committee of the Council on
Cardiovascular Disease in the Young and the Council for High Blood Pressure Research.42
These recommendations were updated in 2014.1 Consensus recommendations for routine ABPM
include the following:
 To confirm the diagnosis of hypertension in a patient with hypertension according to
casual BP Measurements
o Determine whether sustained hypertension or WCH exists.
 To evaluate for the presence of masked hypertension when there is a clinical suspicion of
 To assess BP patterns in high-risk patients
o Assess for abnormal circadian variation in BP, such as blunted dipping or isolated
sleep hypertension in patients with diabetes mellitus, chronic kidney disease, solid
organ transplants, and severe obesity with or without sleep-disordered breathing.
o Assess the severity and persistence of BP elevation in patients at high risk for
hypertensive target-organ damage.
 To evaluate effectiveness of drug therapy for hypertension
o Confirm BP control in treated patients, especially those with secondary forms of
hypertension.
o Evaluate for apparent drug-resistant hypertension.
o Determine whether symptoms can be attributed to drug-related hypotension.
European Society of Cardiology/European Society of Hypertension
In 2013, the European Society of Cardiology and the European Society of Hypertension (ESH)
published joint evidence-based guidelines for the management of arterial hypertension.48 These
guidelines recommend ABPM or home BP monitoring for out-of-office BP measurements
depending on indication, availability, ease, cost of use, and patient preference (class 2b
recommendation [usefulness/efficacy is less well established; use may be considered] based on
level C evidence [consensus expert opinion and/or small studies, retrospective studies, or
registries]). Guideline authors stated, “Whether subjects with WCH can be equaled to true
normotensive individuals is an issue still under debate because, in some studies, the long-term
cardiovascular risk of this condition was found to be intermediate between sustained
hypertension and true normotension, whereas in meta-analyses it was not significantly different
from true normotension when adjusted for age, gender, and other covariates.”48
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MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
European Society of Hypertension
Since 2003, ESH has published consensus-based guidelines on ABPM.49,50 The most recent
update in 2013 identified white coat phenomena, masked hypertension, and nocturnal
hypertension as indications for ABPM.51,52
British Hypertension Society
The British Hypertension Society issued a 2011 guideline on hypertension which was produced
in collaboration with NICE. Refer to the NICE Clinical Guideline (CG) 127 previously
referenced.46 This guideline is scheduled for update in September 2015.
National High Blood Pressure Education Program
The fourth report on the diagnosis, evaluation, and treatment of high BP in children and
adolescents was published in 2004.55 This report made the following statements concerning the
use of ABPM in children and adolescents:
 ABPM is especially helpful in the evaluation of WCH, as well as the risk for
hypertensive organ injury, apparent drug resistance, and hypotensive symptoms with
antihypertensive drugs.
 ABPM is also useful for evaluating patients for whom more information on BP patterns
in needed, such as those with episodic hypertension, chronic kidney disease, diabetes, and
autonomic dysfunction.
 Conducting ABPM requires specific equipment and trained staff. Therefore, ABPM in
children and adolescents should be used by experts in the field of pediatric hypertension
who are experienced in its use and interpretation.
Joint National Committee VII
The seventh report of the Joint National Committee on the prevention, detection, evaluation, and
treatment of high BP,56 released in 2003, includes a brief section on the use of ABPM. The report
states that “[a]mbulatory blood pressure monitoring is warranted for the evaluation of (whitecoat) hypertension in the absence of target organ damage. It is also helpful to assess patients with
apparent drug resistance, hypotensive symptoms with antihypertensive medications, episodic
hypertension, and autonomic dysfunction.”
U.S. Preventive Services Task Force
The U.S. Preventive Services Task Force (USPSTF) published a recommendation that
individuals 18 years and older be screened for hypertension in 2007. This recommendation does
not define methods of screening or mention ABPM. A draft revision of this recommendation is
in progress and is expected to be finalized in 2015. USPSTF also published a recommendation
on screening for hypertension in children and adolescents which concluded that current evidence
is insufficient to assess the balance of benefits and harms of screening for primary hypertension
in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in
childhood or adulthood.
Page 13
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
Medicare National Coverage
Medicare considers ABPM eligible for coverage57 as follows:
“At this point in time, ABPM will be covered for those patients with suspected WCH. Suspected
WCH will be defined as office blood pressure >140/90 mm Hg on at least 3 separate clinic/office
visits with 2 separate measurements made at each visit. In addition, there should be at least 2
blood pressure measurements taken outside the office that are <140/90 mm Hg. There should be
no evidence of end-organ damage. The information obtained by ABPM is necessary in order to
determine the appropriate management of the patient.”
V. DEFINITIONS
TOP
CIRCADIAN: Pertinent to events that occur at approximately 24-hour intervals, such as certain
physiological phenomena.
510 (K) is a premarketing submission made to the FDA to demonstrate that the device to be
marketed is as safe and effective, that is, substantially equivalent (SE), to a legally marketed
device that is not subject to premarket approval (PMA). Applicants must compare their 510(k)
device to one or more similar devices currently on the U.S. market and make and support their
substantial equivalency claims.
HYPERTENSION is a condition in which the blood pressure is higher than 140mm Hg systolic or
90 mm Hg diastolic on three separate readings recorded several weeks apart.
VI. BENEFIT VARIATIONS
TOP
The existence of this medical policy does not mean that this service is a covered benefit under
the member's contract. Benefit determinations should be based in all cases on the applicable
contract language. Medical policies do not constitute a description of benefits. A member’s
individual or group customer benefits govern which services are covered, which are excluded,
and which are subject to benefit limits and which require preauthorization. Members and
providers should consult the member’s benefit information or contact Capital for benefit
information.
VII. DISCLAIMER
TOP
Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute medical
advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of
members. Members should discuss any medical policy related to their coverage or condition with their provider
and consult their benefit information to determine if the service is covered. If there is a discrepancy between this
Page 14
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
medical policy and a member’s benefit information, the benefit information will govern. Capital considers the
information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law.
VIII. CODING INFORMATION
TOP
Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The
identification of a code in this section does not denote coverage as coverage is determined by the
terms of member benefit information. In addition, not all covered services are eligible for
separate reimbursement.
Covered when medically necessary:
CPT Codes®
93784
93786
93788
93790
Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved.
HCPCS
Code
Description
A4670
Automatic Blood Pressure Monitoring
ICD-10-CM
Diagnosis
Code*
I10
R03.1
Description
Essential (primary) hypertension
Elevated blood-pressure reading, without diagnosis of hypertension
*Please see Medicare LCD or NCD for additional covered procedures and diagnoses.
IX.
REFERENCES
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1. 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- 1135. PMID 24591341
2. U.S. Food and Drug Administration (FDA). Welch Allyn ABPM 1600 pre-market
notification: 510(k) summary, 06/27/2002.
http://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pmn&id=K021
756. Accessed April 27, 2016.
3. 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.
Page 15
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
4. LeFevre F, Aronson N. Technology Assessment for ambulatory blood pressure
monitoring for adults with elevated office blood pressure. February 2001.
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id27TA.pdf
Accessed April 27, 2016.
5. 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):335-339. PMID 12055412
6. 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):323327. PMID 12055410
7. 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. 2010;340:c1104. PMID 20392760
8. 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):2145-2152. PMID 17420350
9. 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):319-331. PMID
10602536
10. 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. Nov 4 2014. PMID
25376639
11. Martin U, Haque MS, Wood S, et al. Ethnicity and Differences Between Clinic and
Ambulatory Blood Pressure Measurements. Am J Hypertens. Nov 13 2014. PMID
25398890
12. National High Blood Pressure Education Program (NHBPEP) Working Group Report
On Ambulatory Blood Pressure Monitoring U.S.DHHS In: Program. NHBPE, ed1992.
13. 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 5 2000;102(10):1139-1144.
PMID 10973843
14. Staessen JA, Thijs L, Fagard R, et al. Predicting cardiovascular risk using
conventional vs ambulatory blood pressure in older patients with systolic hypertension.
Systolic Hypertension in Europe Trial Investigators. JAMA. Aug 11 1999;282(6):539546. PMID 10450715
Page 16
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
15. Gustavsen PH, Hoegholm A, Bang LE, et al. White coat hypertension is a
cardiovascular risk factor: a 10-year follow-up study. J Hum Hypertens. Dec
2003;17(12):811-817. PMID 14704724
16. Khattar RS, Senior R, Lahiri A. Cardiovascular outcome in white-coat versus sustained
mild hypertension: a 10- year follow-up study. Circulation. Nov 3 1998;98(18):18921897. PMID 9799210
17. Ohkubo T, Kikuya M, Metoki H, et al. Prognosis of "masked" hypertension and "whitecoat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year
follow-up from the Ohasama study. J Am Coll Cardiol. Aug 2 2005;46(3):508-515.
PMID 16053966
18. Strandberg TE, Salomaa V. White coat effect, blood pressure and mortality in men:
prospective cohort study. Eur Heart J. Oct 2000;21(20):1714-1718. PMID 11032699
19. Ugajin T, Hozawa A, Ohkubo T, et al. White-coat hypertension as a risk factor for the
development of home hypertension: the Ohasama study. Arch Intern Med. Jul 11
2005;165(13):1541-1546. PMID 16009871
20. Verdecchia P, Porcellati C, Schillaci G, et al. Ambulatory blood pressure. An
independent predictor of prognosis in essential hypertension. Hypertension. Dec
1994;24(6):793-801. PMID 7995639
21. Gaborieau V, Delarche N, Gosse P. Ambulatory blood pressure monitoring versus selfmeasurement of blood pressure at home: correlation with target organ damage. J
Hypertens. Oct 2008;26(10):1919-1927. PMID 18806615
22. Salles GF, Cardoso CR, Muxfeldt ES. Prognostic influence of office and ambulatory
blood pressures in resistant hypertension. Arch Intern Med. Nov 24
2008;168(21):2340-2346. PMID 19029499
23. Cuspidi C, Rescaldani M, Tadic M, et al. White-coat hypertension, as defined by
ambulatory blood pressure monitoring, and subclinical cardiac organ damage: a metaanalysis. J Hypertens. Nov 6 2014. PMID 25380162
24. Martin CA, McGrath BP. White-coat hypertension. Clin Exp Pharmacol Physiol. Jan
2014;41(1):22-29. PMID 23682974
25. Fagard RH, Cornelissen VA. Incidence of cardiovascular events in white-coat, masked
and sustained hypertension versus true normotension: a meta-analysis. J Hypertens.
Nov 2007;25(11):2193-2198. PMID 17921809
26. 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):1554-1564. PMID 17620947
27. Verdecchia P, Reboldi GP, Angeli F, et al. Short- and long-term incidence of stroke in
white-coat hypertension. Hypertension. Feb 2005;45(2):203-208. PMID 15596572
Page 17
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
28. Pickering TG, Shimbo D, Haas D. Ambulatory blood-pressure monitoring. N Engl J
Med. Jun 1 2006;354(22):2368-2374. PMID 16738273
29. 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):355370. PMID 12055415 30. 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):1290-1299. PMID 18550999
31. 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. 2011;342:d3621. PMID 21705406
32. 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):123134. PMID 20940712
33. Lovibond K, Jowett S, Barton P, et al. Cost-effectiveness of options for the diagnosis of
high blood pressure in primary care: a modelling study. Lancet. Oct 1
2011;378(9798):1219-1230. PMID 21868086
34. Addison C, Varney S, Coats A. The use of ambulatory blood pressure monitoring in
managing hypertension according to different treatment guidelines. J Hum Hypertens.
Aug 2001;15(8):535-538. PMID 11494091
35. Staessen JA, Byttebier G, Buntinx F, et al. Antihypertensive treatment based on
conventional or ambulatory blood pressure measurement. A randomized controlled
trial. Ambulatory Blood Pressure Monitoring and Treatment of Hypertension
Investigators. JAMA. Oct 1 1997;278(13):1065-1072. PMID 9315764
36. Staessen JA, Den Hond E, Celis H, et al. Antihypertensive treatment based on blood
pressure measurement at home or in the physician's office: a randomized controlled
trial. JAMA. Feb 25 2004;291(8):955-964. PMID 14982911
37. Aylett M, Marples G, Jones K. Home blood pressure monitoring: its effect on the
management of hypertension in general practice. Br J Gen Pract. Sep
1999;49(446):725-728. PMID 10756615
38. Rickerby J. The role of home blood pressure measurement in managing hypertension:
an evidence-based review. J Hum Hypertens. Jul 2002;16(7):469-472. PMID 12080430
39. Weisser B, Mengden T, Dusing R, et al. Normal values of blood pressure selfmeasurement in view of the 1999 World Health Organization-International Society of
Hypertension guidelines. Am J Hypertens. Aug 2000;13(8):940-943. PMID 10950404
40. Verdecchia P, Palatini P, Schillaci G, et al. Independent predictors of isolated clinic
('white-coat') hypertension. J Hypertens. Jun 2001;19(6):1015-1020. PMID 11403348
Page 18
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
41. 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):218-223. PMID 20520632
42. 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):433-451. PMID 18678786
43. Valent-Moric B, Zigman T, Zaja-Franulovic 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
44. Sorof JM, Portman RJ. White coat hypertension in children with elevated casual blood
pressure. J Pediatr. Oct 2000;137(4):493-497. PMID 11035827
45. Matsuoka S, Kawamura K, Honda M, et al. White coat effect and white coat
hypertension in pediatric patients. Pediatr Nephrol. Nov 2002;17(11):950-953. PMID
12432440
46. Hypertension: Clinical management of primary hypertension in adults. NICE clinical
guideline 127 www.nice.org.uk/guidance/CG127. Accessed November 2014.
47. Dasgupta K, Quinn RR, Zarnke KB, et al. The 2014 Canadian Hypertension Education
Program recommendations for blood pressure measurement, diagnosis, assessment of
risk, prevention, and treatment of hypertension. Can J Cardiol. May 2014;30(5):485501. PMID 24786438
48. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the
management of arterial hypertension: the Task Force for the Management of Arterial
Hypertension of the European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC). Eur Heart J. Jul 2013;34(28):2159-2219. PMID
23771844
49. O'Brien E, Asmar R, Beilin L, et al. European Society of Hypertension
recommendations for conventional, ambulatory and home blood pressure
measurement. J Hypertens. May 2003;21(5):821-848. PMID 12714851
50. O'Brien E, Asmar R, Beilin L, et al. Practice guidelines of the European Society of
Hypertension for clinic, ambulatory and self blood pressure measurement. J Hypertens.
Apr 2005;23(4):697-701. PMID 15775768
51. O'Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position
paper on ambulatory blood pressure monitoring. J Hypertens. Sep 2013;31(9):17311768. PMID 24029863
Page 19
MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
52. Parati G, Stergiou G, O'Brien E, et al. European Society of Hypertension practice
guidelines for ambulatory blood pressure monitoring. J Hypertens. Jul
2014;32(7):1359-1366. PMID 24886823
53. Williams B, Poulter NR, Brown MJ, et al. Guidelines for management of hypertension:
report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J
Hum Hypertens. Mar 2004;18(3):139-185. PMID 14973512
54. Appel LJ, Robinson KA, Guallar E, et al. Utility of blood pressure monitoring outside
of the clinic setting. Evid Rep Technol Assess (Summ). Nov 2002(63):1-5. PMID
15523745
55. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in
children and adolescents. Pediatrics. Aug 2004;114(2 Suppl 4th Report):555-576.
PMID 15286277
56. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure: the JNC 7 report. JAMA. May 21 2003;289(19):2560-2572. PMID 12748199
57. Coverage Determinations Manual, Part 1, Section 20.19, Ambulatory Blood Pressure
Monitoring (Rev. 1, 10-03- 03). Centers for Medicare and Medicaid Services 2008;
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/ncd103c1_part1.pdf. Accessed April 27,
2016.
X. POLICY HISTORY
TOP
MP 6.002 CAC 4/29/03
CAC 11/30/04
CAC 10/25/05
CAC 9/26/06
CAC 7/31/07
CAC 7/29/08
CAC 7/28/09 Consensus Review
CAC 5/25/10 Adopted BCBSA Criteria
CAC 4/26/11 Consensus Review, Adopt BCBSA, changed title. No change to policy
statements.
CAC 2/28/12 Revised policy criteria statement from investigational to medically
necessary according to BCBSA policy revision. Added FEP variation to FEP Medical
Policy. Removed Medicare variation to NCD 20.19.
CAC 9/24/13 Consensus review. References updated; no change to the policy
statements. No coding changes.
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MEDICAL POLICY
POLICY TITLE
AUTOMATED AMBULATORY BLOOD PRESSURE MONITORING FOR
THE DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH ELEVATED
OFFICE BLOOD PRESSURE
POLICY NUMBER
MP-6.002
CAC 7/22/14 Consensus review. References updated. Rationale and policy
guidelines added. No change to policy statements. Added Medicare variation
referencing NCD 20.19 Ambulatory Blood Pressure Monitoring.
CAC 7/22/15 Consensus review. No changes to the policy statements.
References and rationale updated. Codes reviewed.
CAC 7/26/16 Consensus review. No change to policy statements. Reference links
updated. Coding reviewed
Admin update 1/1/17: Product variation section reformatted.
TOP
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance
Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all
companies.
Page 21