Criteria
Ambulatory Blood Pressure Monitoring (ABPM) maybe be considered medically necessary for ANY of the following indications:
Adults
- 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 <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 for any other indication 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.
Children/Adolescents
ABPM may be considered medically necessary in children/adolescents greater than or equal to age five (5) in ANY of the following settings:
- Confirming the diagnosis of hypertension including differentiating true hypertension from "white coat" hypertension:
- 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 for any other indication 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.
ABPM is considered experimental/investigational and therefore non-covered in ANY of the following situations because the medical literature does not support its use in these conditions:
- For blood pressure monitoring of individuals with heart failure; or
- For blood pressure monitoring of pregnant women who do not meet any of the criteria listed above; or
- For diagnosing malignant hypertension. Under accepted guidelines, malignant hypertension requires urgent hospital admission for appropriate investigation and treatment; or
- For individuals with an irregular cardiac rhythm (e.g., atrial fibrillation); or
- For monitoring normal blood pressure readings in the medical setting of individuals with documented evidence of end-organ damage (e.g., nephropathy, electrocardiographical changes, left ventricular hypertrophy, angina, myocardial infarction, cerebrovascular accident, transient ischemic attack) or cardiovascular risk factors (e.g., diabetes mellitus, smoking, hypercholesterolemia).
ABPM for more than 24 hours is considered not medically necessary.
Procedure Codes
