Hypertensive Disorders of Pregnancy

Number: 0368

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses hypertensive disorders of pregnancy.

1. Experimental, Investigational, or Unproven

   Aetna considers the following interventions experimental, investigational, or unproven because the effectiveness of these approaches has not been established (not an all-inclusive list):

   1. Obstetrical hypertension programs because they have not been proven to be more effective than member self-management performed in concert with supervision by an obstetrician in reducing fetal or maternal morbidity and mortality;
   2. PEPredictDx for identification of women at high-risk for pre-eclampsia.

2. Related Policies

   • CPB 0025 - Automated Ambulatory Blood Pressure Monitoring - for medical necessity criteria for ambulatory blood pressure monitoring
   • CPB 0548 - Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, and Pacemaker Monitors - for coverage of blood pressure monitors for home use
   • CPB 1093 - Remote Physiologic Monitoring (RPM)

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
CPT codes not covered for indications listed in the CPB:
0390U	Obstetrics (preeclampsia), kinase insert domain receptor (KDR), Endoglin (ENG), and retinol-binding protein 4 (RBP4), by immunoassay, serum, algorithm reported as a risk score
HCPCS codes not covered for indications listed in the CPB:
S9211	Home management of gestational hypertension, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code)
S9212	Home management of postpartum hypertension, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code)
S9213	Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code)
ICD-10 codes not covered for indications listed in the CPB:
O10.011 - O10.019 O10.911 - O10.919	Hypertensive heart disease and hypertension complicating pregnancy, childbirth, and the puerperium
O10.111 - O10.119, O10.211 - O10.219, O10.311 - O10.319, O11.1 - O11.9	Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium
O10.411 - O10.419	Hypertension secondary, complicating pregnancy, childbirth, and the puerperium
O11.1 - O11.9	Pre-existing hypertensive disorder with superimposed proteinuria
O13.1 - O13.9	Gestational (pregnancy induced) hypertension without significant proteinuria
O14.00 - O14.03 O14.90 - O14.95	Gestational (pregnancy induced) hypertension with significant proteinuria
O14.10 - O14.13	Severe pre-eclampsia
O15.00 - O15.9	Eclampsia in pregnancy
O16.1 - O16.9	Unspecified maternal hypertension

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Background

Obstetrical hypertension programs offer a "package" approach to the outpatient care of the hypertensive pregnant patient. These programs typically use a device to measure blood pressure and pulse, and to transmit measurements of daily weight, fetal movement count, and urine proteinuria. The programs do not assure patient compliance with physician instructions regarding the ambulatory management of hypertension.

For mild preeclampsia, conservative management is recommended by the American College of Obstetricians and Gynecologists (ACOG) for any woman not undergoing delivery. Conservative management involves monitoring the patient's blood pressure, proteinuria, renal and hepatic function, platelet counts, and serial sonography for fetal growth. The frequency with which these parameters are monitored should depend on the gestational age and circumstances of the patient and fetus. Inpatient or outpatient management may be appropriate.

An ACOG Practice Bulletin on hypertension in pregnancy (ACOG, 2019) recommends that pregnant women with hypertension be instructed on measuring blood pressure at home. "Although out-of-office and self-monitoring of blood pressure has not been evaluated in pregnant women with hypertension, the literature examining nonpregnant women with hypertension suggests that it is safe to use in both populations. Presumed advantages of out-of-office and self-monitoring include patient convenience, increased therapeutic adherence, confirmation of white coat hypertension, and assistance with adjusting medications when there is uncertainty. . . Procedures for the use of home blood pressure monitoring are available and emphasize patient training, use of appropriately validated devices, and clear instructions. . . . Home monitoring may reduce the frequency of office visits in cases with marginal blood pressure control."

Lanssens et al. (2017) reported on a single-center retrospective cohort "pilot study" to evaluate the added value of a remote follow-up program for pregnant women diagnosed with gestational hypertension. The authors noted that this was the first study of the added value of remote monitoring for women with gestational hypertension. The study was performed in the outpatient clinic of a second-level prenatal center in Belgium, where pregnant women with gestational hypertension received remote monitoring or conventional care. Women consenting to remote monitoring received obstetric surveillance by a wireless blood pressure monitor, a smart body analyzer, and a pulse oximeter. Pregnant women participating in the prenatal remote follow-up program were asked to perform one blood pressure measurement in the morning and one in the evening, one weight measurement a day, and wear an activity tracker day and night until delivery or hospital admission. The data from the monitoring devices were transmitted to a web-based dashboard. Predetermined alarm signals were set; one midwife performed remote follow-up of all transformed data on the dashboard. She had to discriminate between normal and alarm signals of systolic blood pressure >140 mmHg, diastolic blood pressure >90 mmHg, or weight gain >1 kg/day. Alarm events were communicated with the obstetrician in charge to discuss management options before contacting and instructing patients at home. Types of interventions were:

1. expectant management;
2. ambulatory blood sampling and 24-h urine collection at home;
3. adjustment of the antihypertensive therapy or physical activity;
4. admission to the antenatal ward; and
5. induction of labor.

Therapeutic interventions were according to local management. Primary study endpoints include number of prenatal visits and admissions to the prenatal observation ward. Secondary outcomes include gestational outcome, mode of delivery, neonatal outcome, and admission to neonatal intensive care (NIC). Of the 166 patients diagnosed with gestational hypertension, 53 received remote monitoring and 113 conventional care. After excluding 5 patients in the remote monitoring group and 15 in the conventional care group because of the missing data, 48 patients in remote monitoring group and 98 in conventional care group were taken into final analysis. The remote monitoring group had more women diagnosed with gestational hypertension, but less with preeclampsia when compared with conventional care (81.25% vs 42.86% and 14.58% vs 43.87%). Compared with conventional care, univariate analysis in remote monitoring showed less induction, more spontaneous labors, and less maternal and neonatal hospitalizations (48.98% vs 25.00%; 31.63% vs 60.42%; 74.49% vs 56.25%; and 27.55% vs 10.42%). This was also true in multivariate analysis, except for hospitalizations.  The authors concluded that a remove monitoring follow-up of women with gestational hypertension is a promising tool in prenatal care.

A systematic evidence review of telehealth interventions in obstetrics and gynecology (DeNicola et al., 2020), commenting on this study, noted that, "although there was a reasonable consistent trend toward the outcomes observed, outcomes were imprecise, with small sample size and two different clinical parameters (GDM and gestational hypertension)."  The review also stated that there was a trend toward a high risk of selection bias in this study, also noting that there was an imbalance in number of participants assigned to each group. The review observed that this study reported no difference in clinical outcomes, without reporting data to support this conclusion. The review also stated that the applicability of this study to the U.S. health care system must be viewed with caution, given that this study was performed outside of the United States.

A randomized controlled trial of remote monitoring for gestational hypertension is currently underway (Lanssens et al., 2020).

24-Hour Ambulatory Blood Pressure Monitoring for Identification of Pregnant women at Risk of Hypertensive Disorders of Pregnancy

Sommer et al. (2024) noted that early detection and management of HDP and hypertensive disorders post-partum are essential. In a systematic review and meta-analysis, these investigators examined the state of 24-hour ambulatory blood pressure (ABP) use; and in a subset of studies, assessed 24-hour ABP parameters in the prediction and identification of HDP. They carried out a comprehensive literature search in March of 2022 for English language studies published after 2000. In a subset of studies in this review, these researchers conducted a meta-analysis summarizing 24-hour, day-time, and night-time standardized mean difference (SMD; hedge's g) in SBP and DBP during pregnancy for individuals later diagnosed with HDP and those without. A total of 69 studies met all established criteria and were included in this systematic review, and a subgroup of studies that reported HDP outcomes (n = 14) were included in the meta-analysis. Of the 69 studies, 31 (45.61%) used 24-hour ABP devices that were not validated for pregnant individuals. Birthing women diagnosed with HDP had elevated 24-hour, day-time, and night-time SBP and DBP during 2nd and 3rd trimesters of pregnancy. The authors concluded that a noticeable gap existed in the use of validated 24-hour ABP devices for pregnant and post-partum populations. Variations existed regarding the timing of 24-hour ABP measurements, especially across trimesters.

PEPredictDx

PEPredictDx is a test designed to measure patient’s serum of 3 protein biomarkers (kinase insert domain receptor [KDR], endoglin [ENG], and retinol binding protein 4 [RBP4]) for pre-eclampsia (PE); its algorithm reported as a PE risk score to identify high-risk PE patients. However, there is a lack of evidence regarding the effectiveness of this test.

Risk Factors of Hypertensive Disorders in Pregnant Women at High Risk for Gestational Diabetes

Nicoli et al. (2025) stated that women with gestational diabetes (GDM) have increased risk of hypertensive disorders in pregnancy (HDP); however, knowledge remains limited for women with high-risk metabolic profiles, regardless of GDM diagnosis. These researchers examined the prevalence of HDP among women at high risk for GDM, while simultaneously identifying potential predictive clinical risk factors of HDP. Pregnant women who carried out a 75-g oral glucose tolerance test (OGTT) for the selective screening (based on pre-pregnancy risk factors) of GDM were prospectively enrolled (October 2019 to June 2022). The development of HDP was assessed. Logistic regression and ROC-curve analysis were employed to identify predictive risk factors for HDP. Of the 398 women enrolled (53.5% with GDM), 30 (8%) developed HDP. Women developing HDP had more frequently a family history of type 2 diabetes mellitus (T2DM), a personal history of GDM or PE, and demonstrated higher pre-gestational BMI and 1st-trimester fasting plasma glucose. Moreover, at GDM screening, they exhibited higher fasting and 1-hour glucose levels, and higher systolic and diastolic blood pressure (SBP and DBP). At logistic regression, SBP and DBP were the strongest risk factors for HDP. The risk increased for SBP of 127 mmHg or higher (61% sensitivity, 86% specificity, positive predictive value [PPV]: 27%, and negative predictive value [NPV]: 86%) and DBP of 82 mmHg or higher (57% sensitivity, 92% specificity, PPV: 38%, and NPV: 96%). The authors concluded that women at high risk for GDM with poor metabolic profile exhibited higher prevalence of HDP. SBP and DBP at the time of GDM screening may identify women with higher risk of developing HDP, regardless of GDM diagnosis.

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References