Medical Policy
Effective Date:09/18/1995 Title:Ambulatory Blood Pressure Monitoring
Revision Date:01/01/2020 Document:BI113:00
CPT Code(s):93784-93790
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Automated ambulatory blood pressure monitoring is an outpatient procedure using fully or semi-automated devices to measure ambulatory blood pressure at frequent intervals during the day and night in an effort to determine the variability of a patient`s blood pressure due to environmental stresses and to aid in the management of difficult to control high blood pressure.

The use of automated or semi-automated blood pressure monitoring has not been proven to be a substantially more appropriate alternative to intermittent home self-monitoring.  Therefore, coverage is limited.
Medical Statement

Ambulatory blood pressure monitoring is considered medically necessary when all of the following are met:

  1. Documented “white coat “ hypertension defined by all of the following:
    1. At least 3 separate visits where the SBP (systolic blood pressure) is 140-150.
    2. Blood pressure readings have been taken at least twice at each visit and are all in the hypertensive range.
    3. Non-physicians personnel in the physician’s office have taken the blood pressure measurements.
    4. Non-office readings are below 140-150 systolic.
  2. Self-monitoring is either not possible or has consistently shown to be inaccurate.

 

Codes Used In This BI:

93784             Ambulatory blood pressure monitoring, utilizing report-generating software, automated worn continuously for 24 hours or longer; incl recording, scanning analysis, interpretation and report (code revised eff 01/01/2020)

93786             recording only

93788             scanning analysis with report

93790             review with interpretation and report

Limits
Intentially left empty
Reference
  1. Medicare Coverage Database Located at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=20.19&ncd_version=2&basket=ncd%3A20%2E19%3A2%3AAmbulatory+Blood+Pressure+Monitoring

 

  1. Hayes Manual, Ambulatory Blood Pressure Monitoring With Fully Automatic Portable Monitors Dec 2004
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.