CMS Expands Ambulatory Blood Pressure Monitoring Coverage

Kerry Dooley Young

July 04, 2019

Medicare said it will expand its coverage of a diagnostic test that can track blood pressure over a 24-hour cycle. The giant federal health program is seeking to address both cases of hypertension that may not be caught during an office visit and the misdiagnosis of hypotension.

The Centers for Medicare & Medicaid Services (CMS) on Tuesday finalized a revised national coverage policy for ambulatory blood pressure monitoring (ABPM). Since 2001, Medicare has covered ABPM for patients with suspected "white coat hypertension," where a patient's nervousness during an office visit causes a rise in blood pressure.

Under the revised policy, Medicare will pay for ABPM for cases of suspected "masked hypertension," which CMS described as "essentially the opposite of white coat hypertension." CMS defined suspected masked hypertension as 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 or office visits.

In diagnosing suspected masked hypertension, at least two separate measurements should be made at each visit and with at least two blood pressure measurements taken outside the office that are ≥130/80 mm Hg, CMS said.

The agency also said the revised policy also lowers the blood pressure threshold for hypertension from the current policy of 140/90 down to 130/80, aligning it with recommendations from medical societies. Medicare will cover ABPM once per year for eligible patients. This group may include children who are enrolled in Medicare as a result of having end-stage renal disease, CMS said.

Limited Reimbursement a Hindrance

CMS opened a review of its payment policy in response to a 2018 joint request from the American Heart Association and American Medical Association.

The medical associations called for updating Medicare's policy to reflect growing evidence supporting ABPM. The influential United States Preventive Services Task Force in a 2015 recommendation statement on blood pressure monitoring stated that it "found convincing evidence that ABPM is the best method for diagnosing hypertension."

In a release about that recommendation, USPSTF said ABPM "more accurately predicts the risk of strokes, heart attacks, and other health outcomes than blood pressure screening in a medical setting."

Yet, limited reimbursement for APBM has kept this tool from being widely used in clinical practice, Eugene Yang, MD, University of Washington Medicine in Bellevue, told Medscape Medical News.

Home blood pressure monitoring by patients has been used as a surrogate because it is much cheaper than ABPM, Yang said in an interview arranged by the American College of Cardiology. Yang said he welcomed the CMS decision on ABPM, saying it may also persuade private insurers to consider broader coverage.

"There's recognition by Medicare that we need to really address this epidemic of hypertension and that it needs to be more aggressively treated," Yang said.

The United States spent $68 billion in 2016 on medical care related to high blood pressure, a figure that may rise to $154 billion as members of the baby boomer generation age, the AHA and AMA said in their request letter to CMS.

For several years, clinicians have been looking for ways to encourage the use of out-of-office monitoring of high blood pressure, Lawrence R. Krakoff, MD, of the Icahn School of Medicine at Mount Sinai, wrote in an editorial comment in January in the journal Hypertension.

He said Medicare and commercial insurers pay modest fees ($55–$100) for ambulatory monitoring of suspected cases of white coat hypertension.

Krakoff also noted the cost of ambulatory monitoring by physicians and of a patient's own check-ins done at home.

"Up-front costs for the 2 options are markedly different: [approximately] $20,000 to $25,000 for the provider of ambulatory monitoring, not including a suitable computer or $60 to $99 for the patient for a smart home monitor device that can transmit results via smart phone to the provider," Krakoff writes.

Counteract "Haphazard" Measurement

More than 100 clinicians, medical organizations, and companies commented on CMS' draft proposal for expanding coverage of ABPM. Vivek Bhalla, MD, of Stanford University in California, told the agency in a comment last November that ABPM is "rarely performed in large part due to the lack of Medicare coverage." Like Yang, Bhalla depicted CMS' support as potentially having a broader effect on medical care.

"Expanded ABPM coverage may spur innovation in ABPM technologies that will allow for more convenient measurement of longer duration, and could accomplish for blood pressure what is currently available for heart rate monitoring" such as the Zio patch and Apple Watch," he wrote.

Another commenter, Fernando Elijovich, MD, of Vanderbilt University in Nashville, Tennessee, told CMS that expanded coverage of ABPM could counteract "the haphazard and incorrect performance of the measurement in the hurried environment of primary care medicine."

AMA "Pleased"

In making their argument to CMS for broader coverage, the AHA and AMA had argued that ABPM could not only catch cases of hypertension that might otherwise be missed, but also prevent misdiagnosis of the condition. The groups said that research suggested one third of elderly patients receiving hypertension treatment actually are at risk for hypotension.

"Falls due to low blood pressure among the elderly can restrict mobility, either from physical injury or fear of subsequent falls, making it especially important that clinicians not subject their elderly patients to antihypertensive treatment that is unnecessary at best, and potentially harmful at worst," the AHA and AMA write.

AMA President Patrice A. Harris, MD, said in a statement, "We are very pleased that the Centers for Medicare and Medicaid Services (CMS) has taken action to expand Medicare coverage for ambulatory blood pressure monitoring (ABPM) as the AMA and the American Heart Association (AHA) jointly requested.

"We are particularly pleased that CMS modified the final Medicare coverage decision to reflect nearly all of our recommended changes from the proposed coverage decision. This supports our national Target: BP initiative in collaboration with the AHA that aims to ensure every physician has the ability to appropriately diagnose hypertension, which can lead to serious health consequences for patients if left undiagnosed and untreated."

Hypertension. Published online January 1, 2019. Editorial

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