Coverage Policy Manual
Policy #: 1997005
Category: Medicine
Initiated: November 1993
Last Review: January 2024
  Ambulatory Blood Pressure Monitoring
Description:
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 preprogrammed intervals. Ambulatory blood pressure monitoring (ABPM) has the potential to improve the accuracy of diagnosing hypertension and thus improve the appropriateness of medication treatment.
 
Background
Typically done over a 24-hour period with a fully automated device, ambulatory blood pressure monitoring (ABPM) provides more detailed blood pressure information than readings 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. Various BP indices can be derived from the detailed BP information provided by ABPM, including multiple measure times (e.g., 24 hours, daytime, nighttime) and dipping ratio (i.e., calculated by dividing nighttime by daytime systolic BP). Studies evaluating the comparative clinical utility of the various available ABPM BP indices have suggested that higher 24-hour and nighttime BP indices may marginally improve model predictions of greater risk of death and composite cardiovascular events (Yang, 2019).
 
Ambulatory blood pressure monitoring has a number of potential applications. 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 assessing patients having elevated office blood pressure, ABPM is often intended to identify patients with normal ambulatory readings who do not have sustained hypertension. Because 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.
 
Other uses of ABPM include monitoring patients with established hypertension under treatment; evaluating refractory or resistant BP; evaluating whether symptoms such as lightheadedness correspond with BP changes; evaluating night-time BP; examining diurnal patterns of BP; and other potential uses.
 
This evidence review does not directly address other uses of ABPM, including its use 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% to 20% of individuals may exhibit this pattern.
 
Regulatory Status
Many ambulatory BP 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 (FDA, 2022).
 
FDA product code: DXN.
 
Coding
 
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.
Policy/
Coverage:
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Ambulatory blood pressure monitoring meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in the evaluation of an untreated patient when an office-induced increase in blood pressure is suspected (white coat hypertension).
Rationale:
This policy is the result of an Arkansas Blue Cross Blue Shield Technology Assessment initially performed  October 1993.
 
Since completion of the Assessment, relevant publications including a comprehensive evidence report reviewed later have been published. Various organizational and consensus statements have also been issued concerning relevance of ABPM.
 
A report on blood pressure monitoring was completed by the Johns Hopkins Evidence-based Practice Center in November 2002.  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."
 
Organization and consensus panels have established recommendations regarding the use of ABPM: the National High Blood Pressure Education Program; American College of Physicians; the American College of Cardiology; the Joint National Committee on Prevention, Detection and Treatment of High Blood Pressure; the Canadian Hypertension Education Program; the European Society of Hypertension; and the British Hypertension Society. These policy statements are reviewed below.
 
National High Blood Pressure Education Program. The 1990 report recommended that ambulatory blood pressure monitoring is not necessary or clinically appropriate for most hypertensive patients, particularly when target organ damage is apparent (clear candidates for antihypertensive therapy) or when other risk factors are present, i.e., strong family history of diabetes. However, a variety of clinical situations in which ambulatory measurements of blood pressure may be useful were outlined:
    • Borderline hypertension with evidence of target organ damage (e.g., left ventricular hypertrophy, hypertensive retinopathy). Ambulatory pressure reading may be used to confirm or refute high blood pressure as the etiology. Resistant hypertension, diagnosed when multiple antihypertensive medications fail to control high blood pressure. Ambulatory recording can be used to determine if the office reading truly represents resistance to treatment.
    • Episodic hypertension, raising the possibility of a pheochromocytoma or anxiety syndromes. Both of these may be best evaluated with a 24-hour recording of blood pressure.
    • Transient hypotension from antihypertensive drug therapy. This may be difficult to diagnose in the office, ambulatory recordings may allow recognition and avoid overtreatment.
    • “WCH” in patients with elevated office BP. This situation presents a treatment dilemma. Ambulatory blood pressure reading is an objective method of evaluation of these patients, and may be useful for deciding whether to treat with medications.
 
The document noted definitive evidence of improved outcomes associated with the clinical use of ABPM was lacking, particularly in comparison with other methods of measuring blood pressure, e.g., serial measurements by a nonphysician in the office setting or patient self-measurement at home. In addition, the policy statement also points out that several technical issues remain unresolved, such as a standardized approach to data analysis. Furthermore, most of the data that link blood pressure to cardiovascular risk and clinical trials of antihypertensive agents have been primarily based on episodic office readings. It is unclear how 24-hour ambulatory reading should be extrapolated to office settings.
 
American College of Physicians. The American College of Physicians' 1993 position paper consists of an evidence-based review  and policy statement derived from the literature review.  The main findings regarding the use of ABPM for diagnosing hypertension are summarized as follows:
“Self-measured blood pressure and automated ambulatory blood pressure monitoring devices may, in theory, have a specific role in the diagnosis, prognosis, and management of hypertension. The evidence supporting the role of automated ambulatory blood pressure measurement in the diagnosis and treatment of hypertension is, for the most part, indirect. The major studies showing the benefits of treatment in decreasing the morbidity and mortality risks associated with hypertension have used office-based blood pressure measurements to make diagnoses and to treat and follow patients. Similar studies comparing treatment guided by self-measured blood pressures or automated ambulatory blood pressure to treatment guided by office-based blood pressures are required but have not been conducted. Therefore, the available evidence does not warrant widespread dissemination or routine use of automated ambulatory blood pressure measurement at this time. On the other hand, we support a more circumspect use of such devices for research and for the care of subgroups of hypertensive patients with specific clinical problems.”
 
American College of Cardiology. In 1990, the American College of Cardiology issued a policy statement on ambulatory blood pressure monitoring that identified the technology as “investigational,” based in part on technical concerns regarding device accuracy. The position statement was revised in 1994, stating that the previous concerns had been addressed.  Specifically, manufacturing standards had been developed, leading the American College of Cardiology to conclude that “ambulatory blood pressure monitoring has become a mature, clinically applicable (useful) technology for the management of selected hypertensive patients.” However, the policy statement does not appear to be evidence-based; no detailed discussion of the literature accompanied it.
 
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 2005 recommendations  include ABPM as an alternative in the evaluation of patients “without evidence of microvascular target organ damage, diabetes mellitus and/or chronic kidney disease” with blood pressures less than 180 mm Hg systolic and 110 mm Hg diastolic (grade C recommendation). “If ABPM is used, patients can be diagnosed as hypertensive if the mean awake SPB is 135 mmHg or greater or the DBP is 130 mmHg or greater or the DBP is 80 mmHg 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).
 
Joint National Committee VII. The seventh report of the Joint National Committee (JNC) on the prevention, detection, evaluation, and treatment of high blood pressure, released in 2003, includes a brief section on the use of ABPM. The report states that “[ambulatory 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.  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 2003 report from the same society reviewed evidence as to whether patients with WCH might benefit from treatment, concluding that “[evidence to date does not therefore permit a conclusive statement on this issue, but, clearly, if patients with WCH are at risk, the risk is very much smaller than that for patients with sustained hypertension.”
 
British Hypertension Society (BHS) Guidelines issued by the society in 2004  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.
 
2007 Update
A literature search of the MEDLINE database for the period of February 2006 to March 2007 did not identify any published articles on ambulatory blood pressure monitoring that would change the above conclusions; thus, the policy statement remains unchanged.
Many recent publications use ABPM as a research tool for clinical trials of drug treatment in hypertension. Numerous other publications evaluate the use of ABPM in specialized populations, such as children or patients with renal disease.
 
Two updates to specialty society recommendations were identified. The Canadian Hypertension Education program published a 2006 update to their guidelines on blood pressure measurement, diagnosis and assessment of risk.  They included new recommendations on the use of ABPM in the evaluation of ‘masked’ hypertension (normal office BP and elevated out of office BP), but did not include any modifications for patients with isolated office hypertension. The European Society of Hypertension published an update to their recommendations on the clinical value of ABPM.  This update 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.”
 
2010 Update
A review of the literature has been conducted through August 2010.  There was no new literature identified that would prompt a change in the coverage statement.
 
2012 Update
A literature was conducted on the use of ABPM as a diagnostic tool for hypertension.  There were no studies identified that would prompt a change in the coverage statement.
 
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 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 (Pickering, 2006) (Staessen, 2001). A summary of relevant systematic reviews and meta-analyses of these studies is given below.
 
Hansen et al. performed a patient-level meta-analysis using data from four populations in Belgium, Denmark, Japan, and Sweden with a total of 7030 individuals (Hansen, 2007). 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. performed a meta-analysis on 20 cohort studies that evaluated the correlation between ABPM and outcomes, and controlled for office BP in the analysis (Conen, 2008). 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. 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 (Hodgkinson, 2011). Seven studies were identified that compared ABPM with office BP measurements, and three studies were identified that compared ABPM to home self-measurement. Using an 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 et al. compared the accuracy ABPM with home blood pressure measurement for the diagnosis of hypertension (Stergiou, 2011). A total of sixteen studies were included in this analysis. The sensitivity of home blood pressure 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 two methods of BP measurement, as measured by the kappa statistic. In the eleven 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. performed a cost-effectiveness study comparing ABPM with office BP measurement and home measurements (Lovibond, 2011). For the majority of patient indications, ABPM resulted in the greatest amount of quality-adjusted life years (QALYs) gained, and in individuals over the age of 50 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.
 
2014 Update
A literature search conducted through February 2014 did not reveal any new information that would prompt a change in the coverage statement.
 
2015 Update
A literature search conducted through December 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A 2014 meta-analysis study 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 (Cuspidi, 2014). 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 (Martin, 2014). The authors attributed the latter finding to the frequent use of antihypertensive treatment in WCH.
 
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 ABPM-guided 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.
 
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 recommendations (Mancia, 2013) 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:
      • BP that is not below target despite receiving appropriate chronic antihypertensive therapy (Grade C);
      • Symptoms suggestive of hypotension (grade C); or
      • 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).
  • 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 (Urbina, 2008)
 
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
      • Determine whether sustained hypertension or white coat hypertension exists.
  • To evaluate for the presence of masked hypertension when there is a clinical suspicion of hypertension but normal or prehypertensive casual measurements
  • To assess BP patterns in high-risk patients
      • 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.
      •  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
      • Confirm BP control in treated patients, especially those with secondary forms of hypertension.
      • Evaluate for apparent drug-resistant hypertension.
      • 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 published joint evidence-based guidelines for the management of arterial hypertension (Mancia, 2013). 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 equalled 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.”
 
 
Since 2003, the European Society of Hypertension has published consensus-based guidelines on ABPM (O’Brien E, 2003; O’Brien E, 2014). The most recent update in 2013 identified white-coat phenomena, masked hypertension, and nocturnal hypertension as indications for ABPM (O’Brien E, 2013; Parati, 2014).
 
British Hypertension Society
The British Hypertension Society issued a 2011 guideline on hypertension which was produced in collaboration with the National Institute for Health and Care Excellence (NICE). Refer to the NICE Clinical Guideline (CG) 127 previously referenced (NICE, 2014). This guideline is scheduled for update in September 2015.
 
2017 Update
A literature search conducted through December 2016 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A systematic review by Piper and colleagues was performed for the U.S. Preventive Services Task Force (USPSTF) and identified 11 cohort studies that compared ABPM with alternate measurement methods for predicting cardiovascular events (Piper, 2015).Six studies were rated good quality and 5 were rated fair quality. There was a significant correlation between ABPM measures and outcomes in most studies. For each 10-mm increase in the average 24-hour SBP, the hazard ratio (HR) for fatal and nonfatal cardiovascular events ranged from 1.11 to 1.42, and the HR for stroke ranged from 1.28 to 1.40.
 
In the systematic review published by Piper for USPSTF, 7 studies of diagnostic accuracy were identified (Piper, 2015). Four were rated high quality and 3 moderate quality. Four studies directly compared ABPM with automated office BP readings. Using ABPM as the reference standard, the sensitivity of office BP measurement for the diagnosis of hypertension ranged from 51% to 91%, specificity ranged from 97% to 98%, and the positive predictive value ranged from 76% to 84%.
 
 2018 Update
A literature review was conducted using the MEDLINE database through December 2017.
 
Canadian Hypertension Education Program
 
The 2016 annual update to the Canadian Hypertension Education Program was accompanied by an additional publication issuing a new algorithm that strongly recommends the performance of out-of-office measurement (ABPM or home blood pressure monitoring) after the first visit, specifically to identify patients with white coat hypertension (WCH) early in the process. It was emphasized that out-of-office measurement is preferred to serial standardized office measurement and the latter should be used only when the resources (human, technical, or financial) to perform out-of-office measurement are not available (Leung, 2016; Cloutier, 2015).
 
 
 
European Society of Hypertension
 
In 2016, the Society made specific recommendations for children and adolescents; measurements made
with the purpose of diagnosis, evaluation during treatment, as well as in clinical trials and other conditions, in which the presence of orthostatism or rapid and episodic elevation of BP are difficult to detect in the office. The authors stated: “Especially in children, 24-hour ABPM should be recommended
before starting antihypertensive treatment, to avoid treating with drugs children with ‘white-coat
hypertension’ (Lurbe, 2016).
 
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2018. No new literature was identified that would prompt a change in the coverage statement.
   
2020 Update  
Annual policy review completed with a literature search using the MEDLINE database through December 2019. No new literature was identified that would prompt a change in the coverage statement.
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2020. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Typically done over a 24-hour period with a fully automated device, ambulatory blood pressure monitoring (ABPM) provides more detailed blood pressure (BP) information than readings typically obtained during office visits. The greater number of readings with ABPM ameliorates the variability of single BP measurements and is more representative of the circadian rhythm of BP. Various BP indexes can be derived from the detailed BP information provided by ABPM, including multiple measure times (e.g., 24 hours, daytime, nighttime) and dipping ratio (i.e., calculated by dividing nighttime by daytime systolic BP). Studies evaluating the comparative clinical utility of the various available ABPM BP indexes have suggested that higher 24-hour and nighttime BP indexes may marginally improve model predictions of greater risk of death and composite cardiovascular events (Yang, 2019).
 
In 2019, the American Heart Association published a new scientific statement on blood pressure monitoring in humans that provides an overview about blood pressure measurement overall (Muntner, 2019). This scientific statement includes a summary of current knowledge about ambulatory blood pressure monitoring on topics such as medical staff or provider training; devices, cuffs and equipment; patient preparation and instruction; frequency and number of readings; duration of monitoring, and analysis of readings.
 
In 2016 and 2019, the National Institute for Health and Care Excellence (NICE) updated its 2011 guidance on hypertension (NICE, 2016; NICE, 2019). For diagnosing hypertension, the NICE made the following recommendations for ambulatory blood pressure monitoring (ABPM):
 
    • "If the clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
    • If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) 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."
    • Confirm diagnosis of hypertension in people with a clinic blood pressure of 140/90 mmHg or higher AND ABPM daytime average or HBPM average of 135/85 mmHg or higher
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2021. No new literature was identified that would prompt a change in the coverage statement.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2022. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
In 2022, the American Heart Association updated its 2014 recommendations on routine ambulatory blood pressure monitoring (ABPM) in children and adolescents, which included the following (Flynn, 2014; Flynn, 2022):
 
    • "To confirm the diagnosis of hypertension in a patient with hypertension on the basis of clinic BP measurements:
      • Distinguish between ambulatory hypertension and WCH [white coat hypertension].
    • To better assess BP in a patient with clinic BP persistently in the elevated but not hypertensive range.
    • To evaluate for possible masked hypertension when there is a clinical suspicion of hypertension, but clinic BP readings are normal or in the elevated BP range.
    • To evaluate for possible masked hypertension when there is clinical suspicion of hypertension, but clinic BP readings are normal or in the elevated BP range.
    • To assess BP patterns in high-risk patients:
      • Assess for abnormal circadian variation in BP, such as abnormal dipping, or isolated nocturnal hypertension in patients with diabetes, CKD [chronic kidney disease], solid-organ transplant, and severe obesity with or without sleep-disordered breathing.
      • Assess the severity and persistence of BP elevation in patients at high risk for hypertensive TOD [target organ damage].
    • To optimize drug therapy for hypertension:
      • Confirm BP control in treated patients
      • Evaluate for pseudo-resistant hypertension
      • Determine if symptoms suggestive of hypotension can be confirmed as such.
    • An ABPM device suitable for use in children should be selected:
      • Only oscillometric or auscultatory ABP devices that have been validated according to American National Standards Institute (ANSI)/Association for the Advancement of Medical Instrumentation (AAMI)/International Organization for Standardization (ISO) should be used. The British Hypertension standard is acceptable for devices marketed before publication of the ANSI/AAMI/ISO standards.
      • Appropriate cuff sizes as recommended in the 2017 CPG [clinical practice guideline] must be available for the device selected."
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2023. No new literature was identified that would prompt a change in the coverage statement.
CPT/HCPCS:
93784Ambulatory blood pressure monitoring, utilizing report generating software, automated, worn continuously for 24 hours or longer; including recording, scanning analysis, interpretation and report
93786Ambulatory blood pressure monitoring, utilizing report generating software, automated, worn continuously for 24 hours or longer; recording only
93788Ambulatory blood pressure monitoring, utilizing report generating software, automated, worn continuously for 24 hours or longer; scanning analysis with report
93790Ambulatory blood pressure monitoring, utilizing report generating software, automated, worn continuously for 24 hours or longer; review with interpretation and report
References: Addison C, Varney S, Coats A.(2001) The use of ambulatory blood pressure monitoring in managing hypertension according to different treatment guidelines. J Hum Hypertens 2001; 15:535-8.

Am College of Cardiology. Ambulatory blood pressure monitoring. Position Statement. JACC 1994; 23:1511-3.

Ambulatory blood pressure monitoring with fully automatic portable monitors. Hayes Directory, Dec 2004.

Appel LJ, Stason WB.(1993) Ambulatory blood pressure monitoring and blood pressure self-measurement in the diagnosis and management of hypertension. Ann Intern Med, 1993; 118:867-82.

Brown MA, Bowyer L, et al.(2001) Twenty-four-hour automated blood pressure monitoring as a predictor of preeclampsia. Am J Ob Gyn 2001; 185:618-22.

Campbell JR, Myers MG, McKay DW.(1999) Is usual measurement of blood pressure meaningful? Blood Press Monit 1999; 4:71-6.

Carels RA, Sherwood A, Blumenthal JA.(1998) High anxiety and white coat hypertension. Letter. JAMA 1998; 279:197-8.

Chobanian AV, Bakris GL, et al.(2003) The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA, 2003; 289:2560-72.

Cloutier L, Daskalopoulou SS, Padwal RS, et al.(2015) A New Algorithm for the Diagnsosis of Hypertension in Canada. Can J Cardiol. May 2015; 31(5):620-630. PMID 25828374

Conen D, Bamberg F.(2008) Noninvasive 24-h ambulatory blood pressure and cardiovascular disease: a systematic review and meta-analysis. J Hypertens 2008; 26(7):1290-9.

Cuspidi C, Rescaldani M, Tadic M, et al.(2014) White-coat hypertension, as defined by ambulatory blood pressure monitoring, and subclinical cardiac organ damage: a meta-analysis. J Hypertens. Nov 6 2014. PMID 25380162

Ernst ME, Bergus GR.(2002) Noninvasive 24-hour ambulatory blood pressure monitoring: Overview of technology and clinical applications. Pharmacother 2002; 22:597-612.

Feldman RD, Campbell N, et al.(1999) 1999 Canadian recommendations for the management of hypertension. CMAJ 1999; 161 sup 12:S1-17.

Flynn JT, Daniels SR, Hayman LL, et al.(2014) Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. May 2014; 63(5): 1116-35. PMID 24591341

Flynn JT, Kaelber DC, Baker-Smith CM, et al.(2017) Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. Sep 2017;140(3). PMID 28827377

Flynn JT, Urbina EM, Brady TM, et al.(2022) Ambulatory Blood Pressure Monitoring in Children and Adolescents: 2022 Update: A Scientific Statement From the American Heart Association. Hypertension. Jul 2022; 79(7): e114-e124. PMID 35603599

Food and Drug Administration (FDA).(2002) Welch Allyn ABPM 1600 pre-market notification: 510(k) summary. 2002; https://www.accessdata.fda.gov/cdrh_docs/pdf2/K021756.pdf. Accessed June 1, 2022.

Gardner SF, Schneider EF.(2001) 24-Hour ambulatory blood pressure monitoring in primary care. J Am Board Fam Pract 2001; 14:166-71.

Hansen TW, Kikuya M, Thijs L et al.(2007) Prognostic superiority of daytime ambulatory over conventional blood pressure in four populations: a meta-analysis of 7,030 individuals. J Hypertens 2007; 25(8):1554-64.

Hemmelgarn BR, McAlister FA, et al.(2005) The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1-blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol, 2005; 21:645-56.

Hemmelgarn BR, McAlister FA, et al.(2006) The 2006 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 1 - Blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol, 2006; 22:573-81.

Hodgkinson J, Mant J, Martin U et al.(2011) 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.

Jula A, Puuka P, Karanko H.(1999) Multiple clinic and home blood pressure measurements versus ambulatory blood pressure monitoring. Hypertension 1999; 34:262-6.

Khattar RS, Senior R, Lahiri A.(2001) Prognostic value of direct, continuous ambulatory blood pressure monitoring in essential hypertension. J Clin Hypertens (Greenwich) 2001; 3:90-8.

Kok RH, Beltman FW, et al.(1999) Home blood pressure measurement: reproducibility and relationship with left ventricular mass. Blood Press Monit 1999; 4;65-9.

Lenfant C, Chobanian AV, et al.(2003) Seventh report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7): Resetting the hypertension sails. Hypertension, 2003; 41:1178-9.

Leung AA, Nerenberg K, Daskalopoulou SS, et al.(2016) Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention and Treatment of Hypertension. Can J Cardiol. May 2016; 32(5):569-588. PMID 27118291.

Lovibond K, Jowett S, Barton P et al.(2011) Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study. Lancet 2011; 378(9798):1219-30.

Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al.(2016) 2016 European Society of Hypertension Guidelines for the Management of High Blood Pressure in Children and Adolescents. J Hypertens. Oct 2016; 34(10):1887-1920 PMID 27467768

Mallion JM, Baguet JP, et al.(1999) Clinical value of ambulatory blood pressure monitoring. J Hypertens 1999; 17:585-95.

Mancia G, Fagard R, Narkiewicz K, et al.(2013) 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

Manning G, Rushton L, Millar-Craig MW.(1999) Clinical implications of white coat hypertension: an ambulatory blood pressure monitoring study. J Hum Hypertens 1999; 13:817-22.

Mansoor GA, White WB.(1995) Ambulatory blood pressure monitoring in current clinical practice and research. Curr Opin Nephrol Hypertens 1995; 4:531-7.

Martin CA, McGrath BP.(2014) White-coat hypertension. Clin Exp Pharmacol Physiol. Jan 2014;41(1):22-29. PMID 23682974

Muntner P, Shimbo D, Carey RM, et al.(2019) Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association. Hypertension. May 2019; 73(5): e35-e66. PMID 30827125

Myers MG, Haynes RB, Rabkin SW.(1999) Canadian hypertension society guidelines for ambulatory blood pressure monitoring. Am J Hypertens 1999; 12:1149-57.

Myers MG.(2001) Ambulatory blood pressure monitoring in clinical practice. Can J Cardiol 2001; 17:581-6.

National High Blood Pressure Education Working Group.(1990) National High Blood Pressure Education Program Working Group report on ambulatory blood pressure monitoring. Arch Inter Med, 1990; 150:2270-80.

National Institute for Health and Care Excellence.(2016) Hypertension in adults: diagnosis and management [CG127]. 2016; www.nice.org.uk/guidance/CG127. Accessed April 17, 2020.

National Institute for Health and Care Excellence.(2019) Hypertension in adults: diagnosis and management [NG136]. 2019; https://www.nice.org.uk/guidance/ng136. Accessed April 17, 2020.

O'Brien E, Asmar R, Beilin L, et al.(2003) European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens. May 2003;21(5):821-848. PMID 12714851

O'Brien E, Asmar R, Beilin L, et al.(2005) 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 5775768

O'Brien E, Asmar R, et al.(2005) Practice guidelines of the European Society of Hypertension for clinic, ambulatory and self blood pressure measurement. J Hypertension, 2005; 23:697-701.

O'Brien E, Parati G, Stergiou G, et al.(2013) European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. Sep 2013;31(9):1731-1768. PMID 24029863

Parati G, Stergiou G, O'Brien E, et al.(2014) European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring. J Hypertens. Jul 2014;32(7):1359-1366. PMID 24886823

Phillips RA, Diamond JA.(1999) Ambulatory blood pressure monitoring and echocardiography noninvasive techniques for evaluation of the hypertensive patient. Prog Cardiovasc Dis 1999; 41:397-440.

Pickering TG, Shimbo D, Haas D.(2006) Ambulatory blood-pressure monitoring. N Engl J Med 2006; 354(22):2368-74.

Piper MA, Evans CV, Burda BU, et al.(2015) Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. Feb 3 2015;162(3):192-204. PMID 25531400

Sega R, Trocino G, Lanzarotti A, et al.(2001) Alterations of cardiac structure in patients with isolated office, ambulatory, or home hypertension: Data for the general population (pressione Arteriose Monitorate E Loro Associazioni [PAMELA] Study). Circ 2001; 104:1385-92.

Sheps SG, Clement DL, et al.(1994) Ambulatory blood pressure monitoring. Hypertensive Diseases Committee, American College of Cardiology. J Am Coll Cardiol, 1994; 23:1511-3.

Siu AL, Force USPST.(2015) Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. Nov 17 2015;163(10):778-786. PMID 26458123

Staessen JA, Asmar R, De Buyzere M et al.(2001) Task Force II: blood pressure measurement and cardiovascular outcome. Blood Press Monit 2001; 6(6):355-70.

Staessen JA, Beilin L, et al.(1999) Task Force IV: Clinical use of ambulatory blood pressure monitoring. Blood Press Monit 1999; 4:319-31.

Stergiou GS, Bliziotis IA.(2011) Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review. Am J Hypertens 2011; 24(2):123-34.

United States Preventive Services Task Force(2015) High Blood Pressure in Adults: Screening. 2015; http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/high-blood-pressure-in-adults-screening?ds=1&s=Blood pressure.

Urbina E, Alpert B, Flynn J, et al.(2008) 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

Veglio F, Rabbia F, et al.(2001) Ambulatory blood pressure monitoring and clinical characteristics of the true and whitecoat resistant hypertension. Clin Exp Hypertens 2001; 23:203-11.

Verdecchia P, Reboldi GP, Angeli F et al.(2005) Short- and long-term incidence of stroke in white-coat hypertension. Hypertension 2005; 45(2):203-8.

Whelton PK, Carey RM, Aronow WS, et al. 2017(2018) ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. May 15 2018;71(19):2199-2269. PMID 29146533

Williams B, Poulter NR, et al.(2004) Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Human Hypertension, 2004; 18:139-185.

Yang WY, Melgarejo JD, Thijs L, et al.(2019) Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes. JAMA. Aug 06 2019; 322(5): 409-420. PMID 31386134

Yarows SA.(1998) Ambulatory blood pressure monitoring. Letter. JAMA 1998; 279:196-7.
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