|Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure|
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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 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 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 blood pressure (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.”
- 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
A series of CPT codes describe the various steps in ambulatory blood pressure monitoring, e.g., recording (93786), scanning analysis (93788), and physician review and report (93790). These separate CPT codes may be used if different individuals perform the individual tasks. However, if one physician performs all of the above services, CPT code 93784 may be used. Code 93784 is a comprehensive code describing recording, scanning analysis, and interpretation and report.
BlueCard/National Account Issues
Evidence on whether ABPM improves health outcomes for patients with elevated office BP will be summarized in 3 general areas of research:
- Reference values for ABPM
- Impact of ABPM on outcomes (clinical trials)
- Accuracy of ABPM as a diagnostic test for hypertension
- Prospective cohort studies
- 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. (2, 3) Studies that have compared ABPM measurements to office measurement consistently reveal lower values for ABPM. Therefore, it is not possible to use reference values for office blood pressure to evaluate the results of ABPM.
Reference values for ABPM have been derived by several methods. 1) Estimates of population-based ABPM results to define the range and distribution of ABPM values. 2) Direct comparisons of the average values for ABPM and office blood pressure, to determine the level of ABPM, which corresponds to a office blood pressure (BP) of 140/90, and 3) Correlations of ABPM results with cardiovascular outcomes to determine the ABPM levels at which the risk for cardiovascular events increases, or is similar to the risk for an office BP of 140/90. (4, 5)
Although the 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. A task force from a Consensus Conference on ABPM considered data on the statistical distribution of ABPM, the correlation with office BP, and the correlation with cardiovascular outcomes in deriving recommendations for reference values for ABPM. (6) Their recommendations are summarized in the following chart:
Impact of ABPM on outcomes
Clinical Trials. Direct evidence of the efficacy of ABPM improving outcomes in this setting would be obtained from randomized controlled trials (RCTs) comparing outcomes of: 1) patients diagnosed and treated based on conventional blood pressure measurements alone to 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 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.” (7) RCTs using ABPM for monitoring treatment response have been conducted but not to diagnose hypertension. However, a substudy of the Systolic Hypertension in Europe (Syst-Eur) trial did address this question indirectly.
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. A substudy evaluated 695 patients (from the total Syst-Eur sample of 4,695 patients) who underwent 24-hour ABPM in addition to the usual study protocol. Conventional blood pressure was defined from the mean of 6 baseline clinic blood pressures: 2 readings obtained with the patient seated at 3 baseline visits equal to or more than 1 month apart. (8) Participants were classified into 3 groups based on ABPM readings: nonsustained hypertension (i.e., WCH), mild-sustained hypertension, and moderate-sustained hypertension. The 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. (9) analyzed data from an apparently overlapping subset of 808 older individuals from the Syst-Eur trial followed up a median of 4.4 years in the same trial with isolated systolic hypertension measured conventionally (systolic BP [SBP]: 160–219 mm Hg, diastolic BP [DBP]: <95 mm Hg). Blood pressures were also measured by ABPM; average systolic and diastolic blood pressures were higher with conventional measurements (by 21.9 and 1.9 mm Hg, respectively). ABPM was significantly associated with cardiovascular endpoints, 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 to normotensive and sustained hypertensive patients (the latter being treated). Studies should control for important potential confounders such as adequacy of blood pressure control, age, sex, smoking, lipid levels, and diabetes. Well-designed and conducted prospective cohort studies finding untreated WCH patients having a cardiovascular event risk similar to 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 future cardiovascular outcomes in WCH patients, normotensive patients, and sustained hypertensive patients. (10-17) These studies have been generally consistent in reporting that the cardiovascular risk for patients with WCH is intermediate, between that of hypertensive patients and normotensive patients.
At least 3 meta-analyses have been published that summarize the results of the available cohort studies. Fagard and Cornelissen (18) summarized data from 7 cohort studies with a total of 11,502 patients that compared outcomes in 4 groups of patients: normotensive patients, WCH patients, “masked” hypertensive patients, and sustained hypertensive patients. The 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]: 0.84–1.50). There was an increased risk for patients with “masked” hypertension (HR: 2.00; 95% CI: 1.58–2.52) and patients with sustained hypertension (HR: 2.28; 95% CI: 1.87–2.78).
Hansen et al. (19) used patient-level data from 4 previous cohorts of patients to construct an international database on ambulatory BP monitoring. This database included 7,069 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: 0.96–1.53, p=0.09). There were significant increases in risk for patients with “masked” hypertension (HR: 1.62; 95% CI: 1.35–1.96, p<0.0001) and patients with sustained hypertension (HR: 1.80; 95% CI: 1.59–2.03, p<0.0001).
A third pooled analysis by Verdecchia et al. (20) included studies conducted in the United States, Italy, and Japan. This analysis compared short- and long-term stroke risk among 4,406 individuals with essential hypertension and 1,549 normotensive controls; none 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 white-coat hypertensives 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.
Accuracy of ABPM as a diagnostic test for hypertension
Studies of the accuracy of ABPM as a diagnostic test for hypertension are of two types. First, prospective cohort studies that correlate the results of ABPM with future cardiovascular events, and compare this correlation to office blood pressure (BP) measurements, provides indirect evidence on the accuracy of ABPM 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 gold standard for diagnosis. For these types of studies, ABPM is often considered to be the gold standard, and the accuracy of other methods of measuring BP is compared against ABPM.
Prospective cohort studies. Many prospective cohort studies have compared ABPM with office BP in predicting cardiovascular events. Although the results of these studies are not entirely consistent, the majority report that ABPM has greater predictive ability for cardiovascular events compared to office BP measurement. (21, 22) A summary of relevant systematic reviews and meta-analyses of these studies is given below.
Hansen et al. (19) performed a patient-level meta-analysis using data from four populations in Belgium, Denmark, Japan, and Sweden with a total of 7,030 individuals. The predictive value of ABPM and clinic BP for fatal and non-fatal 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. (23) performed a meta-analysis on 20 cohort studies that evaluated the correlation between ABPM and outcomes and controlled for office BP in the analysis. These authors reported that ABPM was a strong predictor of cardiovascular outcomes and that controlling for office BP had little effect on the risk estimates. These results support the hypothesis that the risk information obtained from ABPM is independent of that from office BP.
Cross-sectional studies. Numerous studies have directly compared ABPM with office BP and/or home self-measured BP. Hodgkinson et al. (24) 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. Seven studies were identified that compared ABPM with office BP measurements, and 3 studies were identified that compared ABPM to home self-measurement. Using a 24-hour ABPM threshold of 135/85, clinic BP measurements had a sensitivity of 74.6% (95% CI: 60.7-84.8%) and a specificity of 74.6% (95% CI: 47.9-90.4%). Home BP self-measurement had a sensitivity of 85.7% (78.0-91.0%) and a specificity of 62.4% (48.0-75.0%). 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 (25) compared the accuracy of ABPM with home blood pressure measurement for the diagnosis of hypertension. A total of 16 studies were included in this analysis. The sensitivity of home BP measurement, compared to ABPM, ranged from 36-100% with a median value of 74%. Specificity ranged from 44-96% with a median value of 84%. This study also reported the diagnostic agreement between the 2 methods of BP measurement, as measured by the kappa statistic. In the 11 studies where kappa could be calculated, the range of scores was 0.37 to 0.73, with a median value of 0.46. This kappa level indicates moderate agreement between ABPM and home monitoring in the diagnosis of hypertension.
Lovibond et al. (26) performed a cost-effectiveness study comparing ABPM with office BP measurement and home measurements. For the majority of 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. It was cost-saving in all patient groups compared to alternatives and remained the most cost-effective alternative under the majority of sensitivity analysis. As a result of these findings, 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. (27-29) Some studies have compared home self-monitoring to ABPM and office measurement for management of medication treatment. (30-32) Others have attempted to determine predictors of WCH based on clinical factors and office BP readings. (33) However, these areas of research do not provide specific evidence on the use of ABPM for diagnosing and treating patients with elevated office blood pressure and thus are not included in the final evidence base for this policy.
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 (HTN) from white coat hypertension (WCH). The evidence on use in children and adolescents is of a similar type for adults but of a smaller quantity. A representative sample of studies identified is described below.
In a study from Europe, 139 children and adolescents between the ages of 4-19 years of age with elevated office BP were evaluated by ABPM monitoring. (34) A total of 32/139 (23.0%) of participants had WCH as evidenced by a normal 24-hour ABPM result. Of patients with true hypertension, 21/107 (19.6%) had evidence of target organ damage, compared to none of the patients with WCH. In a similar study from the U.S., 67 otherwise healthy children underwent ABPM, 51 of whom had an elevated office BP. (35) Using 3 definitions of WCH of varying BP cutoffs, WCH was identified in 22-53% of children with elevated office BP. In a study from Japan, 206 children and adolescents between the ages of 6-25 years underwent ABPM, 70 of whom had elevated office BP. (36) Among the 70 patients with elevated office BP, 33/70 (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 HTN and 25% of patients with normal office BP.
Ambulatory blood pressure monitoring performed over a 24-hour period is a more accurate method for evaluating blood pressure compared to office measurements and home blood pressure measurements. Reference values for normal and abnormal ambulatory blood pressure monitoring (ABPM) results have been derived from epidemiologic research. 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 to 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 to normotensive and hypertensive patients.
Studies comparing home blood pressure monitoring and office monitoring to ABPM as the gold standard report that the sensitivity and specificity of alternative methods of diagnosing hypertension are suboptimal. Substantial percentages of patients with elevated office BP are found to have normal BP on ABPM, and 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, ambulatory blood pressure monitoring may be considered medically necessary for the evaluation of patients with elevated office blood pressure.
Practice Guidelines and Consensus Statements
NICE. The UK’s National Institute for Health and Clinical Excellence (NICE) issued updated hypertension guidelines in 2011. (37) For diagnosing hypertension, NICE made the following recommendations concerning ABPM:
- If the clinic blood pressure is 140/90 mm Hg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
- When using ABPM to confirm a diagnosis of hypertension, ensure that at least two 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 (CHEP). Guidelines for blood pressure measurement, diagnosis, and risk assessment have been published annually by CHEP. Strength of evidence underlying recommendations is graded ranging from “A” (studies with high internal validity, statistical precision, and generalizability) to “D” (expert opinion).
The 2010 recommendations (38) include ABPM as an alternative in the evaluation of patients “without evidence of target organ damage, diabetes mellitus and/or chronic kidney disease” with blood pressures less than 180 mm Hg systolic (SBP) and 110 mm Hg diastolic (DBP). ABPM is considered an acceptable alternative to continued office BP readings or home self-monitoring to confirm the diagnosis of hypertension. If ABPM is used, patients can be diagnosed as hypertensive if the mean awake SBP is 135 mm Hg or greater or the DBP is 130 mm Hg or greater or the DBP is 80 mm Hg or greater. Other clinical recommendations for ABPM included: 1) untreated patients with mild to moderate clinic blood pressure elevations and without target organ damage (grade B), 2) treated patients with blood pressure that is above target despite appropriate therapy (grade C), 3) treated patients with symptoms of hypotension (grade C), and 4) treated patients with fluctuating office readings (grade D).
European Society of Cardiology. The European Society of Cardiology published updated guidelines on the diagnosis and treatment of hypertension in 2007. These guidelines made the following recommendations:
- Ambulatory blood pressure monitoring may improve prediction of cardiovascular risk in untreated patients.
- 24-hour ambulatory blood pressure monitoring should be considered when:
- Considerable variability of office BP is found over the same or different visits
- High office BP is measured in subjects otherwise at low total cardiovascular risk
- There is marked discrepancy between BP values measured in the office and at home
- Resistance to drug treatment is suspected
- Hypotensive episodes are suspected, particularly in elderly and diabetic patients
- Office BP is elevated in pregnant women and pre-eclampsia is suspected
- Normal values for ABPM should be approximately 125-130/80 for a 24-hour average BP; and 135/85 for average daytime BP.
Joint National Committee VII. The seventh report of the Joint National Committee (JNC) on the prevention, detection, evaluation, and treatment of high blood pressure, (39) 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 (white-coat) 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.”
European Society of Hypertension. The European Society of Hypertension updated guidelines in 2005 pertaining to the use of conventional, ambulatory, and home blood pressure measurement. (40) Outlined are both “accepted” and “potential indications” for the use of ABPM. The listed “accepted indications” include: suspected white-coat, nocturnal, masked, and resistant hypertension, as well as to establish dipper status, and in hypertension of pregnancy.
The 2006 update to their recommendations on the clinical value of ABPM (41) states that “…use of office and ambulatory BP measurements has allowed the identification of a condition characterized by a persistently elevated office BP and a persistently normal ambulatory one.” The guidelines further state that the evidence is conflicting on whether this is a benign condition or one that is associated with increased cardiac risk. Thus, they recommend that “…caution should be used when deciding whether or not such patients should be treated.”
British Hypertension Society (BHS). Guidelines issued by the society in 2004 (42) include discussion of ABPM noting “[l]ike home blood pressure measurements, there are no outcome trials based solely on ABPM values,” and “We do not recommend the use of ABPM for all patients, but it is helpful in specific circumstances.” Those listed circumstances include: unusual blood pressure variability, possible WCH, informing equivocal treatment decisions, evaluation of nocturnal hypertension, evaluation of drug-resistant hypertension, determining the efficacy of drug treatment over 24 hours, diagnoses and treatment of hypertension in pregnancy, and evaluation of symptomatic hypotension.
AHRQ Evidence-Based Practice Center Program. A report on blood pressure monitoring was completed by the Johns Hopkins Evidence-based Practice Center in November 2002. (43) This report comprehensively reviewed evidence relevant to various methods of blood pressure measurement, including review of the utility of ABPM for diagnosing and treating WCH. The evidence from prospective cohort studies was deemed insufficient to determine the risk of cardiovascular events for WCH compared to normotensive patients. The conclusion from cross-sectional studies was that patients with WCH had intermediate-risk profiles between normotensive and hypertensive patients. Furthermore, the authors stated that the "evidence was insufficient to determine whether the risks associated with WCH are sufficiently low to consider withholding drug therapy in this large subgroup of hypertensive patients." (43)
National High Blood Pressure Education Program. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents was published in 2004. (44) This report made the following statements concerning the use of ABPM in children and adolescents:
- ABPM is especially helpful in the evaluation of white-coat hypertension, 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.
Medicare National Coverage Determination
Medicare considers ABPM eligible for coverage (45) 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.”
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- National High Blood Pressure Education Program Working Group on High Blood Pressure in C, Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004; 114(2 Suppl 4th Report):555-76.
- Coverage Determinations Manual, Part 1, Section 20.19, Ambulatory Blood Pressure Monitoring (Rev. 1, 10-03-03). Centers for Medicare and Medicaid Services 2008. Available online at: http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf. Last accessed June 2008.
|CPT||93784||Ambulatory blood pressure monitoring, including recording, scanning analysis, interpretation and report|
|93788||Scanning analysis with report|
|93790||Physician review with interpretation and report|
|ICD-9 Procedure||No Code|
|ICD-9 Diagnosis||401.0-401.9||Essential hypertension code range|
|796.2||Elevated blood pressure reading without diagnosis of hypertension|
|HCPCS||A4670||Automatic blood pressure monitor|
|ICD-10-CM (effective 10/01/14)||I10||Essential (primary) hypertension|
|I11.0-11.9||Hypertensive heart disease code range|
|R03.0-R03.1||Abnormal blood-pressure reading, without diagnosis code range|
|Z01.30-Z01.31||Encounter for examination of blood pressure code range|
|ICD-10-PCS (effective 10/01/14)||Not applicable. ICD-10-PCS codes are only used for inpatient services. Policy is only for outpatient services.|
|Type of Service||DME|
|Place of Service||
Ambulatory Blood Pressure Monitor
Blood Pressure Monitoring, Ambulatory
Monitor, Blood Pressure, Ambulatory
|12/01/95||Add to Durable Medicine section||New policy|
|01/30/98||Replace policy||Reviewed with changes; expanded rationale, no change in policy coverage|
|06/18/99||Replace policy||Updated; policy unchanged|
|10/08/02||Replace policy||Policy updated, new references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated, new references added; no change in policy statement|
|05/23/05||Replace policy||Policy updated with literature review; no change in policy statement|
|04/25/06||Replace Policy||Policy updated with literature review and extensively reorganized; no change in policy statement. HCPCS code added to code table|
|04/17/07||Replace Policy||Policy updated with literature review; references 36 and 37 added. No change in policy statement|
|07/10/08||Replace policy||Policy updated with literature review; references 5, 6, 34, 37, and 39 added. No change in policy statement|
|12/08/11||Replace policy||Policy updated with literature review. Policy statement changed to medically necessary for patients with elevated office blood pressure under certain conditions. References 15-17 deleted, references 4-6, 19, 21, 22, 24-26, 34, 35 added.|
|12/31/12||Replace Policy||Policy updated with literature review. References 34-36, 44 added. No change to policy statement.|