Cigna RPM SMBP Coverage Update

Coverage Summary

This policy defines Remote Physiologic Monitoring (RPM) as the use of non‑invasive digital technologies (software, mobile or wearable devices) to capture and monitor physiologic parameters remotely; Self‑Measured Blood Pressure (SMBP) as the subset of RPM that collects home blood pressure measurements reported to a clinician with subsequent treatment‑plan communication; and Remote Therapeutic Monitoring (RTM) as monitoring of non‑physiologic information (e.g., adherence, pain).

The policy considers RPM medically necessary for the following indications when required criteria are met: COPD, Diabetes Mellitus, Gestational Diabetes, Heart Failure, and Hypertensive Disorders of Pregnancy (HDP). SMBP is considered medically necessary for Hypertension and Hypertensive Disorders of Pregnancy (HDP). RTM is not covered for any indication under this policy.

Coverage applies to health benefit plans administered by Cigna Companies and is subject to the terms of the customer's specific benefit plan document; plan terms, applicable laws/regulations, and individual case review may affect coverage determinations.

Operational thresholds / code thresholds for RPM, SMBP, 99091, and RTM

RPM monitoring duration>= 16 days of a 30-day period

SMBP measurement frequency (CPT 99474)Minimum 12 readings: two readings one minute apart, twice daily over a 30-day period

99091 time requirementMinimum 30 minutes of collection and interpretation time each 30 days

RTM device-days (2-15 day codes)2-15 days in a 30-day period (applicable to device supply RTM codes)

Remote Physiologic Monitoring (RPM) — Medically Necessary Criteria

Remote Physiologic Monitoring (RPM) - Medically Necessary Indications and Required Criteria

RPM (CPT codes 99091, 99445, 99453, 99454, 99457, 99458, 99470, HCPCS G0322) is medically necessary for ANY of the listed indications when ALL of the following are met:

Indications (ANY of)

Chronic Obstructive Pulmonary Disease (COPD)
Diabetes Mellitus
Gestational Diabetes
Heart Failure
Hypertensive Disorders Of Pregnancy (HDP)

Self-Measured Blood Pressure (SMBP) — Medically Necessary Criteria

Self-Measured Blood Pressure (SMBP) - Medically Necessary Indications and Required Criteria

SMBP (CPT codes 99473, 99474) is medically necessary for the listed indications when ALL of the following are met:

Indications (ANY of)

Hypertension
Hypertensive Disorders Of Pregnancy (HDP)

Required operational criteria (ALL of)

Prescribed and administered by a board-eligible or board-certified medical provider or subspecialist (e.g., cardiologist, pulmonologist, endocrinologist), nurse practitioner (NP) or physician assistant (PA)
Physiologic data are electronically collected and automatically uploaded for analysis and interpretation

Not Covered / RTM Coverage Statement

RPM - Not Covered Indications

RPM is not covered or reimbursable for any other indication not listed above, including isolated hypertension.

Any indication not listed as medically necessary under RPM (including isolated hypertension)

Remote Therapeutic Monitoring (RTM) - Coverage Statement

RTM (CPT codes 98975-98981, 98984-98986) is not covered or reimbursable for ANY indication.

All RTM codes and indications are considered not covered/reimbursable under this policy

Billing/Service Requirements for Remote Therapeutic Monitoring (RTM) Treatment Management Services

RTM treatment management services require physician or other qualified health care professional time in a calendar month and at least one real-time interactive communication with the patient or caregiver during the calendar month.

SMBP and RPM Service Descriptions (Code-level)

SMBP and RPM Service Descriptions (code-level descriptors)

Code-level descriptions indicate service components required for billing.

99473: Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration.

99474: Self-measured blood pressure using a device validated for clinical accuracy; separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient.minimum of 12 readings over 30 days

G0322: The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e., remote patient monitoring).

Coding

RPM CPT / HCPCS Codes - Considered Medically Necessary when criteria metCPT|HCPCSCovered

99091	Collection and interpretation of physiologic data; minimum of 30 minutes of time, each 30 days
99445	Device(s) supply with daily recording(s) or programmed alert(s) transmission, 2-15 days in a 30-day period
99453	Initial; set-up and patient education on use of equipment
99454	Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
99457	RPM treatment management services; first 20 minutes interactive communication in a calendar month
99458	Each additional 20 minutes (list separately)
99470	RPM treatment management services; first 10 minutes real-time interactive communication in a calendar month
G0322	Collection of physiologic data transmitted by the patient to the home health agency (remote patient monitoring)

SMBP CPT Codes - Considered Medically Necessary when criteria metCPTCovered

99473	Self-measured blood pressure; patient education/training and device calibration
99474	Self-measured BP; collection of readings over 30 days (minimum 12 readings) and report of averages with treatment plan communication

RTM CPT Codes - Not CoveredCPTNot Covered

98975	RTM initial set-up and patient education
98976	RTM device supply to monitor respiratory system, each 30 days
98977	RTM device supply to monitor musculoskeletal system, each 30 days
98978	RTM device supply to monitor cognitive behavioral therapy, each 30 days
98979	RTM treatment management services; first 10 minutes real-time interactive communication in a calendar month
98980	RTM treatment management services; first 20 minutes interactive communication
98981	RTM treatment management services; each additional 20 minutes (list separately)
98984	RTM device supply for data access/transmission for respiratory system, 2-15 days in a 30-day period
98985	RTM device supply for musculoskeletal system, 2-15 days in a 30-day period
98986	RTM device supply for cognitive behavioral therapy, 2-15 days in a 30-day period

ICD-10-CM Codes - Considered Medically Necessary for RPM/SMBP when criteria metICD-10Covered

E08.00-E13.9	Diabetes mellitus
I50.1-I50.9	Heart failure
J44.0-J44.9	Chronic obstructive pulmonary disease
O10.011-O10.93	Pre-existing hypertension complicating pregnancy, childbirth and the puerperium
O11.1-O11.9	Pre-existing hypertension with pre-eclampsia
O13.1-O13.9	Gestational [pregnancy-induced] hypertension without significant proteinuria
O14.00-O14.95	Pre-eclampsia
O15.00-O15.9	Eclampsia
O16.1-O16.9	Unspecified maternal hypertension
O24.011-O24.93	Diabetes mellitus in pregnancy, childbirth, and the puerperium

1–10 of 12

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Not Covered Diagnosis Codes (RPM/RTM) - All other diagnosis codesICD-10Not Covered

All other diagnosis codes

Any diagnosis codes not specifically listed as covered in this policy are not covered/reimbursable

Remote Therapeutic Monitoring CPT Codes (device setup, supply, monitoring, and management)CPT

98975	Remote therapeutic monitoring initial set-up and patient education on use of equipment
98976	RTM device(s) supply with scheduled recordings/programmed alerts to monitor respiratory system, each 30 days
98977	RTM device(s) supply with scheduled recordings/programmed alerts to monitor musculoskeletal system, each 30 days
98978	RTM device(s) supply with scheduled recordings/programmed alerts to monitor cognitive behavioral therapy, each 30 days
98979	RTM treatment management services, first 10 minutes (requires at least one real-time interactive communication in calendar month)
98980	RTM treatment management services, first 20 minutes (requires at least one interactive communication in calendar month)
98981	RTM treatment management services, each additional 20 minutes (List separately in addition to code for primary procedure)
98984	RTM device supply for respiratory monitoring, 2-15 days in a 30-day period
98985	RTM device supply for musculoskeletal monitoring, 2-15 days in a 30-day period
98986	RTM device supply for cognitive behavioral therapy monitoring, 2-15 days in a 30-day period

Self-Measured Blood Pressure (SMBP) CPT CodesCPT

99473	Self-measured blood pressure: device validated for clinical accuracy; patient education/training and device calibration
99474	Self-measured blood pressure: two readings one minute apart, twice daily over 30 days (min 12 readings), data reported with average systolic/diastolic and communication of treatment plan

Remote Patient Monitoring HCPCSHCPCS

G0322

Collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (remote patient monitoring)

Provider Actions / Billing & Documentation

Documentation Required

Ensure qualifying diagnosis and documentation

Submit RPM/SMBP claims only for covered diagnoses listed in the policy. Ensure the medical record documents a qualifying diagnosis from the policy's ICD-10 list (examples include E08.00–E13.9 for diabetes; I50.1–I50.9 for heart failure; J44.0–J44.9 for COPD; O10.–O16. and related codes for hypertensive disorders of pregnancy and O24.011–O24.93 for diabetes in pregnancy). Claims submitted without a covered diagnosis will be denied.

Billing Rule

RPM device billing frequency

When multiple medical devices are provided, bill services associated with all devices only once per patient per 30-day period and only when at least 16 days of data have been collected. Device supply codes referenced in the policy include 99454 and 99445 (and HCPCS G0322 for home health agency RPM).

Background & Evidence Summary

RPM involves digital technologies to capture and monitor physical or behavioral functioning (examples: pulse, blood pressure, respiratory rate, blood glucose, weight, oxygen saturation). SMBP is a blood‑pressure‑only subset where patients self‑measure and report readings to clinicians with treatment plan communication. RTM captures non‑physiologic data (e.g., medication adherence, pain); per CMS RTM use is limited to musculoskeletal and respiratory conditions.

Evidence: multiple randomized controlled trials, systematic reviews, and meta‑analyses (sample sizes reported across studies) suggest RPM can improve outcomes for COPD, diabetes mellitus, gestational diabetes, heart failure, and hypertensive disorders of pregnancy (reduced ED visits/hospitalizations, improved glycemic control, improved patient engagement and some morbidity benefits). Published data for RTM are limited and currently insufficient to demonstrate improved health outcomes.

Evidence quick-reference

RPM evidenceMultiple RCTs, systematic reviews and meta-analyses (n=17-22,047) suggest improved outcomes for COPD, diabetes, gestational diabetes, heart failure, and HDP

RTM evidenceLimited published data; insufficient evidence to support improved health outcomes

CDC Million Hearts SMBP referenceUpdated Aug 1, 2024 (accessed Mar 12, 2025)

Definitions

Term	Definition
RPM	Remote physiologic monitoring: use of digital technologies to capture and monitor physiologic data remotely; non-invasive for this policy.
SMBP	Self-measured blood pressure: home blood pressure measured by the individual and reported to the provider with subsequent communication of a treatment plan.
RTM	Remote therapeutic monitoring: monitoring of non-physiologic information such as therapy adherence or pain; per CMS limited to musculoskeletal and respiratory conditions.
Real-time interactive communication	A synchronous communication between clinician and patient/caregiver during the calendar month required for certain RTM treatment management codes.

Revision History

5/15/2023New Policy

New policy created 5/15/2023.

5/15/2024Annual Review (material)

Annual Review dated 5/15/2024: Title change; added policy statement for self-measured blood pressure monitoring; removed policy statement criteria requiring FDA approval/clearance; revised policy statement for RPM for any other indication.

9/15/2024Focused Review (material)

Focused Review dated 9/15/2024: Added policy statement for gestational diabetes and hypertensive disorders of pregnancy.

OpenPayer

Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) Overview