1. Aetna considers automated ambulatory blood pressure monitoring medically necessary according to the selection criteria listed below, which are based on guidelines developed by the American College of Physicians.

   Note: Ambulatory blood pressure monitoring for more than 3 days is not considered medically necessary.

   Member must meet any of the following criteria:

   1. Office or "white coat" hypertension: The physician suspects "white coat" hypertension or a transient rise of blood pressure that occurs in the office setting. The member has blood pressure readings repeatedly elevated to a mild degree in the office setting (systolic readings of 140 to 150 mm Hg and/or diastolic readings of 90 to 99 mm Hg) and no definitive diagnosis of hypertension has been established despite all of the following:

      1. The physician has performed at least three blood pressure measurements at least 1 week apart in the office; and
      2. Blood pressure measurements by non-physicians (e.g., nurse, technician) have been done and mild hypertensive readings have been obtained; and

      3. Member has repeated blood pressure measurements at home over at least one month, and the diagnosis of hypertension remains in question.

   2. Resistant hypertension: Ambulatory blood pressure monitoring is considered medically necessary prior to instituting an invasive investigation (e.g., renin vein assays, angiogram for renal artery stenosis) for secondary causes of hypertension for members with hypertension that is refractory to medications.
   3. Evaluation of hypotensive symptoms: Ambulatory blood pressure monitoring is considered medically necessary for members with hypotensive symptoms and/or syncopal events that are thought to be related to antihypertensive medications.
   4. Nocturnal angina: Ambulatory blood pressure monitoring is considered medically necessary to investigate blood pressure changes in members with nocturnal angina.
   5. Episodic hypertension: Ambulatory blood pressure monitoring is considered medically necessary for members whose symptomatology (paroxysms of excessive sweating, palpitations, apprehension) suggests episodic hypertension secondary to an adrenal tumor (e.g., pheochromocytoma), and office blood pressure measurements are repeatedly normal.

   6. Evaluation of syncope: Ambulatory blood pressure monitoring is considered medically necessary when used in conjunction with a 24-hour Holter monitor (see CPB 019 - Holter Monitors ) to determine whether symptoms of syncope or near syncope are the direct result of an arrhythmia.

2. Aetna considers the use of ambulatory blood pressure monitoring experimental and investigational in any of the following situations because the medical literature does not support its use in these conditions:

   1. For routine monitoring to establish the clinical diagnosis of hypertension or to evaluate the member's blood pressure responses to treatment; or
   2. For members with an irregular cardiac rhythm (e.g., atrial fibrillation).  Blood pressure readings are inconsistent and unreliable when an irregular cardiac rhythm is present due to variances in pulse volume; or
   3. For monitoring normal or borderline hypertensive blood pressure readings in the medical setting of members with documented evidence of end-organ damage (e.g., nephropathy, electrocardiographical changes, left ventricular hypertrophy, angina, myocardial infarction, cerebrovascular accident, transient ischemic attack) or cardiovascular risk factors (e.g., diabetes mellitus, smoking, hypercholesterolemia); or
   4. For diagnosing malignant (accelerated phase) hypertension. Under accepted guidelines, malignant hypertension requires urgent hospital admission for appropriate investigation and treatment; or
   5. For blood pressure monitoring of pregnant women who do not meet any of the criteria listed above; or
   6. For blood pressure monitoring of persons with heart failure.

Automated ambulatory blood pressure (BP) monitoring is an outpatient procedure using fully automated devices to measure ambulatory BP at frequent intervals during the day and night in an effort to determine the variability of a patient's BP due to environmental stresses and to aid in definitively establishing a diagnosis of hypertension before committing the patient to life-long antihypertensive therapy.

Since treatment is rarely urgent in the absence of severe hypertension, the physician's diagnosis of hypertension should be substantiated first by repeated office readings by well-trained non-physicians. If the diagnosis is not established by non-physicians taking BP measurement, a month trial of patient self-measurement of BP in the home at varying times during the day should be tried.

Patients with borderline hypertensive measurements in the office setting should have basic cardiovascular tests done. Those who have evidence of target-organ damage or other cardiovascular risk factors should receive non-pharmacological and/or pharmacological treatments without further investigation. Studies have unequivocally demonstrated that these patients have a significant risk of developing cardiovascular disease and will benefit from antihypertensive therapy. Patients with no evidence of target-organ damage and no risk factors should be classified by a trial of self-measured BP; drug treatment should be considered for patients with consistently elevated readings in this setting.

The accuracy, patient acceptability and mechanical reliability of ambulatory BP devices remain controversial. Studies have not shown that continuous ambulatory monitoring is superior to random, frequent patient self-measurement with a calibrated BP cuff. In addition, data management and analysis have not been standardized and are arbitrarily determined. Studies that showed the relationship between BP and cardiovascular disease risk and the clinical trials that documented the efficacy of antihypertensive drug therapy were based on casual office measurements. Furthermore, the American College of Physicians recommends that a physician-measured diastolic BP reading of 90 to 99 mm Hg be utilized to establish a firm diagnosis of hypertension.

Automated ambulatory BP monitoring is not medically necessary for the diagnosis and management of hypertension in most patients; however, its use is indicated in rare subgroups of hypertensive patients with specific clinical problems, which are identified by the patient selection criteria indicated.

In a systematic review, Goyal, et al. (2005) stated that "ambulatory blood pressure monitoring has established its use in the definition of white coat hypertension and monitoring of treatment of essential hypertension.  Any role for ambulatory blood pressure monitoring in heart failure is not well defined….Prospective controlled studies on the impact of treatments on circadian blood pressure profile in congestive heart failure patients are needed".