This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.
AMBULATORY BLOOD PRESSURE MONITORING
MEDICALLY NECESSARY
Ambulatory blood pressure monitoring (ABPM) is considered medically necessary and, therefore, covered once annually for individuals who meet the following criteria:
- Suspected white coat hypertension demonstrated by the following:
- The individual has an average office blood pressure of systolic blood pressure between 130 mm Hg and 160 mm Hg or diastolic blood pressure between 80 mm Hg and 100 mm Hg on two separate clinic/office visits, with two separate measurements made at each visit, and blood pressure less than 130/80 mm Hg documented on at least two separate blood pressure measurements taken outside the office.
- Suspected masked hypertension demonstrated by the following:
- The individual has an average office blood pressure between 120 mm Hg and 129 mm Hg for systolic blood pressure or between 75 mm Hg and 79 mm Hg for diastolic blood pressure on two separate clinic/office visits with at least two separate measurements made at each visit and with at least two blood pressure measurements taken outside the office that are equal to or greater than 130/80 mm Hg.
ABPM devices must meet all of the following specifications:
- Must be capable of producing standardized plots of blood pressure measurements for 24 hours with daytime and night-time windows and normal blood pressure bands demarcated
- Must be provided to individuals with oral and written instructions and a test run in the professional provider's office must be performed
- Must have output interpreted by the treating professional provider
NOT MEDICALLY NECESSARY
All other uses for ABPM are considered not medically necessary and, therefore, not covered by the Company because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.
HOME BLOOD PRESSURE MONITORING DEVICES
NONAUTOMATIC HOME BLOOD PRESSURE MONITORING DEVICES
Nonautomatic home blood pressure monitoring (HBPM) devices are considered medically necessary and, therefore, covered for individuals with end-stage renal disease who are receiving home dialysis.
AUTOMATIC HOME BLOOD PRESSURE MONITORING DEVICES
An automatic HBPM (A4670) device is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.
REPLACEMENT HOME BLOOD PRESSURE MONITORING DEVICES
The Company may determine the reasonable useful lifetime of a specific nonautomatic HBPM device based on the manufacturer's recommendation.
In the absence of manufacturer's recommendations, the Company may determine the reasonable useful lifetime of a nonautomatic HBPM device, but it is generally not less than 5 years. Replacement of one or more of its components (parts) that are necessary for its proper functioning due to misuse, abuse, or failure to adequately maintain or care for the item is excluded from coverage.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include, but are not limited to, records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:
STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.
PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.
CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 30 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately 10 days before the individual would exhaust their on-hand supply.
For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.
If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.
