CMS is reconsidering its reimbursement practices for ambulatory blood pressure monitoring (ABPM) at the request of the American Heart Association and the American Medical Association, which authored a joint letter urging the agency to cover ABPM for a broader range of indications.
CMS is soliciting public comments through Nov. 8 on the new National Coverage Determination (NCD), which is expected to be announced next April, according to CMS.
The NCD for ABPM was last updated in 2001 and only allows reimbursement for patients with suspected white coat hypertension, defined as meeting all of the following criteria:
- Office BP greater than 140/90 mm Hg on at least three separate office/clinic visits, with two separate measurements made at each visit.
- At least two documented BP measures below 140/90 mm Hg taken outside of the office.
- No evidence of end-organ damage.
In their request for a new National Coverage Analysis, the AHA and AMA said “a large body of evidence” since the last NCD supports ABPM as an effective tool to diagnose hypertension. The organizations cited a 2015 recommendation from the U.S. Preventive Services Task Force, which gave a Grade A recommendation for obtaining measurements outside of the office setting for confirming a diagnosis of hypertension before starting treatment.
“The USPSTF found convincing evidence that ABPM is the best method for diagnosing hypertension,” that recommendation read. “Although the criteria for establishing hypertension varied across studies, there was significant discordance between the office diagnosis of hypertension and 12- and 24-hour average blood pressures using ABPM, with significantly fewer patients requiring treatment based on ABPM.
“Elevated ambulatory systolic blood pressure was consistently and significantly associated with increased risk for fatal and nonfatal stroke and cardiovascular events, independent of office blood pressure. For these reasons, the USPSTF recommends ABPM as the reference standard for confirming the diagnosis of hypertension.”
The AHA and AMA echoed these sentiments in the letter to CMS, noting ABPM may be particularly relevant for the older Medicare population. In addition to confirming a diagnosis of hypertension or white-coat hypertension, the AHA and AMA said ambulatory monitoring could help uncover masked hypertension and elevated blood pressure during sleep, which also have significant impacts on public health.
Also, survey data indicate cost has been a primary barrier in clinicians not providing their patients with AMBP to confirm hypertension diagnoses, according to the letter.
“ABPM has been shown to be effective at diagnosing a number of blood pressure patterns and comorbid conditions prevalent in the Medicare population which can help ensure Medicare beneficiaries receive appropriate treatment tailored to their individual health needs,” stated the letter, which was signed by AHA president John Warner, MD, and AMA executive vice president and CEO James L. Madara, MD.
“ABPM is also an effective diagnostic tool to preventing overtreatment, a particularly problematic phenomenon among aged Medicare beneficiaries who may experience physical and psychological harm from overly-aggressive antihypertensive treatment that could lead to dangerous drops in blood pressure and subsequent falls.”
As of Monday morning, 18 responses had been logged into CMS’s public comments section, with nearly all of the clinicians and researchers expressing support of expanding the criteria under which ABPM is reimbursed.
“I am a nephrologist and have been treating patients with hypertension for >35 years,” wrote Karen Griffin, MD, with Loyola University Medical Center. “I have seen many patients develop target organ injury due to undiagnosed masked hypertension despite adequate control based solely on clinic BP measurements. The lack of Medicare coverage for ambulatory BP monitoring has clearly had an adverse impact on my ability to effectively diagnose and treat patients with this most devastating silent killer.”
“My support for reimbursement for ABPM, when its use conforms to results of clinical research on its utility, goes well beyond its use as an indispensable diagnostic tool,” wrote Fernando Elijovich, MD, a professor of medicine at Vanderbilt University. “It extends to all other circumstances in which it may improve therapy, prognosis and accurate monitoring or follow-up of hypertensive patients.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.