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Thread: Insurance coverage for equip

  1. #1

    Insurance coverage for equip

    My insurance(Aetna) would not cover my blood pressure cuff for autonomic dysreflexia. They said it was "experimental usage" and there was no CMS code for AD and blood pressure cuffs. A year later, I am still fighting the appeal.

    Has anyone ever had their insurance cover their blood pressure cuff? Any suggestions how to get the thing covered? It is less than $75 but I refuse to pay on principal. If I need to, I want to get CMS to add AD to coverage codes. I use nitropaste and the cuff helps me know when to wipe the paste off.

    Anyone have suggestions? SCI Nurse, will the VA cover them and under what codes?

    Every day I wake up is a good one

  2. #2
    KLD wil have to answer that about VA but the code could be for management of hypertension (or hypotension). They are more ikey to it since you have Nitropaste prescribed. AD is probaby too complicated.


  3. #3
    Not only does the VA cover them for patients at risk for AD, we REQUIRE the patient at risk to get one and learn how to use it. We provide them to patients at risk through their Prosthetics & Sensory Aids coverage (from VA supplies), so there is no "code" for this.

    Have you asked your SCI physician to write a justification? There is nothing "experimental" about taking a blood pressure, and if the insurance does not have AD coded in their manuals, so clerk is just jerking you around. Ask for a review of your request by a physiatrist (at the expense of the insurance company) not just by any physician or nurse.

    It would also be worth it to try it as CWO suggests and have your physician justify it for management of "labile hypertension" which should show up in their coding book.


  4. #4

    Thumbs down

    I use an automated cuff as it is the only way I can take my blood pressure independently. Here is what the insurance says:
    Blood Pressure Monitors and Stethoscopes:

    Notes: Home blood pressure monitors (sphygmomanometers, blood pressure cuffs) and stethoscopes do not meet Aetna’s definition of covered durable medical equipment in that they may be of use in the absence of illness and injury. Following Medicare rules, Aetna covers blood pressure monitors and stethoscopes only for members receiving hemodialysis or peritoneal dialysis in the home.

    Aetna considers automated oscillometer blood pressure (BP) monitors (e.g., Dinamap and Omron) for home use experimental and investigational because they have not been demonstrated to provide better health outcomes than conventional BP monitors (see background).

    See also CPB 025 - Automated Ambulatory Blood Pressure Monitoring
    We have even provided PVA clinical guidelines for the practitioner as well as a letter of appeal.

    Here is more: Home | Help | Contact Us

    Clinical Policy Bulletin:
    Automated Ambulatory Blood Pressure Monitoring
    Number: 0025


    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/American Society of Internal Medicine.

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

    Member must meet any of the following criteria:

    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:

    The physician has performed at least three blood pressure measurements at least 1 week apart in the office; and
    Blood pressure measurements by non-physicians (e.g., nurse, technician) have been done and mild hypertensive readings have been obtained; and
    Member has repeated blood pressure measurements at home over at least one month, and the diagnosis of hypertension remains in question.

    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.
    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.
    Nocturnal angina: Ambulatory blood pressure monitoring is considered medically necessary to investigate blood pressure changes in members with nocturnal angina.
    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.
    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.

    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:

    For routine monitoring to establish the clinical diagnosis of hypertension or to evaluate the member's blood pressure responses to treatment; or
    For members with an irregular cardiac rhythm (e.g., atrial fibrillation). Blood pressure reading are inconsistent and unreliable when an irregular cardiac rhythm is present due to variances in pulse volume; or
    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
    Use of an ambulatory blood pressure monitor for more than 3 days is not considered medically necessary; or
    Use for diagnosing malignant (accelerated phase) hypertension. Under accepted guidelines, malignant hypertension requires urgent hospital admission for appropriate investigation and treatment; or
    Blood pressure monitoring of pregnant women who do not meet any of the criteria listed above; or
    Blood pressure monitoring for heart failure.

    Automated ambulatory blood pressure monitoring is an outpatient procedure using fully automated devices to measure ambulatory blood pressure at frequent intervals during the day and night in an effort to determine the variability of a patient's blood pressure 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 blood pressure measurement, a month trial of patient self-measurement of blood pressures 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-pharmacologic and/or pharmacologic 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 blood pressures; drug treatment should be considered for patients with consistently elevated readings in this setting.

    The accuracy, patient acceptability and mechanical reliability of ambulatory blood pressure devices remain controversial. Studies have not shown that continuous ambulatory monitoring is superior to random, frequent patient self-measurement with a calibrated blood pressure cuff. In addition, data management and analysis have not been standardized and are arbitrarily determined. Studies that showed the relationship between blood pressure 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 blood pressure reading of 90 to 99 mm Hg be utilized to establish a firm diagnosis of hypertension.

    Automated ambulatory blood pressure 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".

    CPT Codes
    CPT codes covered if selection criteria are met:
    Other CPT codes related to the CPB:
    75722 - 75724

    ICD-9 Codes
    ICD-9 codes covered if selection criteria are met:
    227.0 Benign neoplasm of adrenal gland
    401.1, 401.9, 402.10, 402.90, 405.11 - 405.99 Hypertensive disease (except malignant or with heart failure and/or kidney disease)
    413.0 Angina decubitus
    458.0 - 458.9 Hypotension
    780.2 Syncope and collapse
    ICD-9 codes not covered for indications listed in the CPB:
    250.00 - 250.93 Diabetes mellitus
    272.0 Pure hypercholesterolemia
    272.2 Mixed hyperlipidemia
    274.10 - 274.19 Gouty nephropathy
    305.1 Tobacco use disorder
    398.91 Rheumatic heart failure (congestive)
    401.0 Essential hypertension, malignant
    402.00 - 402.01 Hypertensive heart disease, malignant
    402.11 Hypertensive heart disease, benign, with heart failure
    402.91 Hypertensive heart disease, unspecified, with heart failure
    403.00 - 403.91 Hypertensive kidney disease
    404.00 - 404.03 Hypertensive heart and kidney disease, malignant
    404.11 - 404.13 Hypertensive heart and kidney disease, benign, with heart failure, with chronic kidney disease, or with heart failure and chronic kidney disease
    404.91 - 404.93 Hypertensive heart and kidney disease, unspecified, with heart failure, with chronic kidney disease, or with heart failure and chronic kidney disease
    405.01 - 405.09 Secondary hypertension, malignant
    410.00 - 412 Myocardial infarction
    428.0 - 428.9 Heart failure
    429.3 Cardiomegaly
    433.00 - 436 Occlusion and stenosis of precerebral arteries or cerebral arteries, transient cerebral ischemia, or acute, but ill-defined, cerebrovascular disease
    583.0 - 583.9 Nephritis and nephropathy
    584.5 - 584.9 Acute renal failure
    585.1 - 585.9 Chronic kidney disease (CKD)
    586 Renal failure, unspecified
    794.31 Abnormal electrocardiogram [ECG] [EKG]
    796.3 Nonspecific low blood pressure reading
    V22.0 - V24.2 Supervision of pregnancy
    V81.1 Special screening for hypertension
    Other ICD-9 codes related to the CPB:
    194.0 Malignant neoplasm of adrenal gland
    198.7 Secondary malignant neoplasm of adrenal gland
    237.2 Neoplasm of uncertain behavior of adrenal gland
    391.8 Other acute rheumatic heart disease
    392.0 Rheumatic chorea with heart involvement
    404.10 Hypertensive heart and kidney disease, benign, without heart failure or chronic kidney disease
    404.90 Hypertensive heart and kidney disease, unspecified, without heart failure or chronic kidney disease
    413.9 Other and unspecified angina pectoris
    427.0 - 427.9 Cardiac dysrhythmias
    429.4 Functional disturbances following cardiac surgery
    437.2 Hypertensive encephalopathy
    440.1 Atherosclerosis of renal artery
    588.0 Renal osteodystrophy
    588.89 Other specified disorders resulting from impaired renal function
    593.89 Other specified disorders of kidney and ureter
    593.9 Unspecified disorders of kidney and ureter
    642.00 - 642.94 Hypertension complicating pregnancy, childbirth, and the puerperium
    646.20 - 646.24 Unspecified renal disease in pregnancy, without mention of hypertension
    753.20 - 753.29 Obstructive defects of renal pelvis and ureter
    760.0 Maternal hypertensive disorders
    780.8 Hyperhidrosis
    785.1 Palpitations
    796.2 Elevated blood pressure reading without diagnosis of hypertension
    997.1 Cardiac complications
    E942.6 Adverse effects of other antihypertensive agents

    The above policy is based on the following references:
    No authors listed. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993;153(2):154-183.
    Sheps S, Clement DL, Pickering TG, et al. Ambulatory blood pressure monitoring. J Am College Cardiol. 1994;23(6):1511-1513.
    Appel L, Stason WB. Ambulatory blood pressure monitoring and blood pressure self-measurement in the diagnosis and management of hypertension. Ann Intern Med. 1993;118(11):867-882.
    No authors listed. Automated ambulatory blood pressure and self-measured blood pressure monitoring devices: Their role in the diagnosis and management of hypertension. American College of Physicians. Ann Intern Med. 1993;118(11):889-892.
    Sutherland J, Castle C, Friedman R. Hypertension: Current management strategies. J Am Board Fam Pract. 1994;7(3):202-217.
    Carek P, Carson DS, Cooke CE, Weart CW. Clinical implications of white coat hypertension. Am Fam Phys. 1995;52(1):163-168.
    Price D. The hypertensive patient in family practice. J Am Board Fam Pract. 1994;7(5):403-416.
    Zachariah P, Sheps SG, Smith RL. Clinical use of home and ambulatory blood pressure monitoring. Mayo Clin Proc. 1989;64(11):1436-1446.
    Shapiro A, Karschner JK, Glunk DJ, Barnhill BM. Clinical use of ambulatory blood pressure monitoring. Arch Fam Med. 1995;4(8):691-696.
    No authors listed. National High Blood Pressure Education Program Working Group Report on Ambulatory Blood Pressure Monitoring. Arch Intern Med. 1990;150(11):2270-2280.
    Institute for Clinical Systems Integration (ICSI). Hypertension diagnosis and treatment. ICSI Health Care Guidelines No. G15. Bloomington, MN: Institute for Clinical Systems Integration; February 1999.
    U.S. Preventive Services Task Force. Screening for hypertension. In Guide to Clinical Preventive Services. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996:39-51.
    Nordmann A, Frach B, Walker T, et al. Comparison of self-reported home blood pressure measurements with automatically stored values and ambulatory blood pressure. Blood Press. 2000;9(4):200-2005.
    Staessen JA, O'Brien ET, Thijs L, et al. Modern approaches to blood pressure measurement. Occup Environ Med. 2000;57(8):510-520.
    Mengden T, Chamontin B, Phong Chau N, et al. User procedure for self-measurement of blood pressure. First International Consensus Conference on Self Blood Pressure Measurement. Blood Press Monit. 2000;5(2):111-129.
    Staessen JA, Thijs L. Development of diagnostic thresholds for automated self-measurement of blood pressure in adults. First International Consensus Conference on Blood Pressure Self-Measurement. Blood Press Monit. 2000;5(2):101-109.
    O'Brien E, Beevers G, Lip GY. ABC of hypertension. Blood pressure measurement. Part III-automated sphygmomanometry: Ambulatory blood pressure measurement. BMJ. 2001;322(7294):1110-1114.
    Scottish Intercollegiate Guidelines Network (SIGN). Hypertension in older people. A national clinical guideline. SIGN Publication No. 49. Edinburgh, Scotland: SIGN; 2001.
    Bergel E, Carroli G, Althabe F. Ambulatory versus conventional methods for monitoring blood pressure during pregnancy (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford, UK: Update Software.
    Ernst ME, Bergus GR. Ambulatory blood pressure monitoring. South Med J. 2003;96(6):563-568.
    Norderhaug PI. Ambulatory blood pressure measurement. A review of international studies. Oslo, Norway: Norwegian Health Services Research Centre (NHSRC); 2000.
    Bisset AF. Ambulatory versus conventional blood pressure monitoring. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2001.
    Appel L, Robinson K, Guallar E. Utility of blood pressure monitoring outside of the clinic setting. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2002.
    Canadian Coordinating Office of Health Technology Assessment (CCOHTA). 24-hour ambulatory blood pressure monitoring. Pre-assessment No. 15. Ottawa, ON: CCOHTA; January 2003.
    Graves JW, Sheps SG. Does evidence-based medicine suggest that physicians should not be measuring blood pressure in the hypertensive patient? Am J Hypertens. 2004;17(4):354-360.
    National Institute for Clinical Excellence (NICE). Management of hypertension in adults in primary care. Clinical Guideline 18. London, UK: NICE; 2004. Available at: Accessed January 9, 2006.
    Tice JA. Utility of ambulatory blood pressure monitoring. Technology Assessment. San Francisco, CA: California Technology Assessment Forum (CTAF); October 20, 2004. Available at: Accessed January 9, 2006.
    Brown MA, Mangos G, Davis G, Homer C. The natural history of white coat hypertension during pregnancy. BJOG. 2005;112(5):601-606.
    Goyal D, Macfadyen RJ, Watson RD, Lip GY. Ambulatory blood pressure monitoring in heart failure: A systematic review. Eur J Heart Fail. 2005;7(2):149-156.
    Every day I wake up is a good one

  5. #5
    It would seem to me that AD causes episodic hypertension, which is on the list, although clearly not due to the cause they list.
    They claim the monitor is not supported for diagnosis of malignant hypertension. I guess they mean that you need to go to the ER if you experience hypertension. Would they rather pay for repeated ER trips because you suspect that you may have AD, or for a BP monitor that costs a small fraction of one ER visit? What idiots - it's definitely in their direct interest to supply you with the monitor. As you say, AD should be added to thir coverage codes.
    KLD's approach may work.
    - Richard

  6. #6
    I can go to the ER for a $50 co-pay. The cuff was $50. At this point almost a year later, I would have made more than 20 trips. I agree, it is a wast of time and resources.
    Every day I wake up is a good one

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