Modifiedpriority healthPolicy N/A

Blood Pressure Monitors & Ambulatory Blood Pressure Monitoring

This policy defines medical necessity, coverage, and coding for home blood pressure monitors (HBPM) and 24-hour ambulatory blood pressure monitoring (ABPM) for Priority Health members, with product- and program-specific exceptions noted for Medicaid and Medicare Advantage.

Policy Summary

Payerpriority health

PolicyBlood Pressure Monitors & Ambulatory Blood Pressure Monitoring

Policy CodePolicy N/A

Change TypeMaterial content change (HBPM device coverage language removed) and structural additions

Effective Date03/01/2026

Next Review DateN/A

Key ActionPrescribe HBPM and ensure device is provided by a participating DME vendor or pharmacy with correct cuff size documented when submitting requests.

SourceLink

POLICY UPDATE CHANGES

HBPM: Removed 'only devices approved by Priority Health will be covered'.

New Policy scope section, Medical/Professional Society Guidelines section, Government Regulations section listing applicable CMS NCDs or LCDs, and FDA/Regulatory section were added.

1/5yHBPM devices covered (frequency limit)

24-hrABPM monitoring duration specified

93784–93790ABPM CPT codes listed

A4660,A4663,A4670

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Coverage Criteria for HBPM and ABPM

Home Blood Pressure Monitors - Commercial Members

Covered when ALL of the following are met for commercial members:

HBPM commercial coverage: a. HBPM prescribed by a physician; b. HBPM provided by a participating Durable Medical Equipment (DME) vendor or pharmacy with applicable benefit applied; c. Devices must be arm devices only; correct cuff size must be assessed and provided by vendor; one device covered per 5 years.

Home Blood Pressure Monitors - MI Medicaid/Healthy Michigan Plan

Covered when criteria in the current MDHHS Medicaid Provider Manual are met:

HBPM Medicaid coverage: Blood pressure monitors (manual or automatic) may be considered medically necessary when the criteria specified in the current Michigan Department of Health and Human Services (MDHHS) Medicaid Provider Manual are met.

Ambulatory Blood Pressure Monitoring - Medical Necessity

ABPM is medically necessary for any of the following indications:

ABPM indications: 1) Assessing suspected white coat hypertension as defined (office BP >130/80 mm Hg on ≥2 separate visits with 2 measurements each, plus ≥2 out-of-office readings <130/80 mm Hg, and no end-organ damage). 2) Assessing suspected masked hypertension as defined (average office BP 120–129 systolic or 75–79 diastolic on 2 visits with 2 measurements each, plus ≥2 out-of-office readings ≥130/80 mm Hg). 3) Assessing hypertension resistant to increasing medications (failure to achieve target despite concurrent use of 3 antihypertensive agents of different classes or requiring ≥4 medications). 4) Assessing suspected episodic hypertension, including evaluation for nocturnal hypertension and for causes such as pheochromocytoma. 5) Evaluation of postural, postprandial, and drug-induced hypotension (e.g., symptomatic hypotension while taking antihypertensive medications).24-hour monitoring specified

Ambulatory Blood Pressure Monitoring - Exclusions

ABPM exclusions: ABPM is not a covered benefit for Priority Health Medicaid or Healthy Michigan Plan members. ABPM is not covered for any diagnosis for Medicaid. Medicare Advantage members should refer to their Evidence of Coverage for ABPM benefits.

Abbreviated plan-specific coverage: ABPM is not a covered benefit for Priority Health Medicaid or Healthy Michigan Plan members. For traditional Medicaid, ABPM is not covered for any diagnosis. Medicare Advantage members should consult their Evidence of Coverage for ABPM benefits.

Coverage for experimental, investigational, or unproven treatments is excluded under this policy unless an exception is granted. Requests for individual consideration require prior plan approval and will be reviewed by a Priority Health medical director or clinical pharmacist. Exceptions may be considered only in cases such as a terminal illness or a chronic, life‑threatening, severely disabling disease causing serious clinical deterioration.

ABPM coverage is limited to the specific indications listed in this policy. ABPM is not a covered benefit for any other indications beyond those listed. Additionally, for Medicaid products, ABPM is not covered for any diagnosis.

Coding and Clinical Thresholds

BLOOD PRESSURE MONITORS - ICD-10 supporting codesICD-10

I10	Essential (primary) hypertension
I11.0-I11.9	Hypertensive heart disease
I12.0-I12.9	Hypertensive chronic kidney disease
I13.0-I13.2	Hypertensive heart and chronic kidney disease
I15.0-I15.9	Secondary hypertension
I67.4	Hypertensive encephalopathy
I95.0-I95.9	Hypotension
I97.3	Post procedural hypertension
O10.011-O10.93	Pre-existing essential hypertension complicating pregnancy
O11.1-O11.9	Pre-existing hypertension with pre-eclampsia

1–10 of 18

1/2

BLOOD PRESSURE MONITORS - HCPCSHCPCSCovered

A4660	Sphygmomanometer/blood pressure apparatus with cuff and stethoscope (covered for Medicaid only)
A4663	Blood pressure cuff only (covered for Medicaid only)
A4670	Automatic blood pressure monitor

AMBULATORY BLOOD PRESSURE MONITORING - CPT/HCPCSCPTCovered

93784	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; including recording, scanning analysis, interpretation and report
93786	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; recording only.
93788	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; scanning analysis with report
93790	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; review with interpretation and report

Office BP thresholds (ACC/AHA)

Office BP threshold (ACC/AHA)Office blood pressure ≥130/80 mm Hg; corresponding 24-hour ambulatory blood pressure 125/75 mm Hg

Diagnostic basisThresholds based on 2017 ACC/AHA guideline definitions referenced in policy background

Measurement occasionsBased on >2 measurements on >2 separate occasions as per guideline categorization

HBPM replacement and device requirements

Replacement frequencyOne home blood pressure device covered per 5 years

Device type requirementCovered device must be an arm device with correct cuff size assessed and provided by vendor

Provider Requirements, Prior Authorization, and Billing

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain devices and procedures. When prior authorization is required, providers must submit a request demonstrating that the device, service, or procedure is medically necessary. Refer to the Priority Health Provider Manual for details and submission instructions.

Prior authorization when required: submit documentation demonstrating medical necessity
Refer to Priority Health Provider Manual for prior authorization processes

Denial Risk

Investigational / Unproven Treatments — Denial Risk

Coverage for investigational, experimental, or unproven treatments will be denied unless an exception is approved. Individual case review may allow coverage for investigational yet promising treatments, but all determinations require review and approval by a Priority Health medical director or clinical pharmacist. Exceptions may be considered for terminal illnesses or chronic, life‑threatening, severely disabling diseases causing serious clinical deterioration, and require prior plan approval.

Background and Clinical Rationale

Out‑of‑office blood pressure measurement methods — ambulatory blood pressure monitoring (ABPM) and home/self-measured blood pressure monitoring (HBPM) — are used to evaluate suspected white coat and masked hypertension. ABPM is considered the reference standard for confirming elevated office blood pressure because it captures 24‑hour variability, nocturnal blood pressure, and physiologic responses to daily activities, and both ABPM and HBPM better predict cardiovascular risk than office measurements.

Definitions and Diagnostic Thresholds

Suspected white coat hypertension

DefinitionSuspected white coat hypertension: office BP >130/80 mm Hg on at least 2 separate clinic/office visits with 2 measurements at each visit

Out-of-office confirmationAt least two documented out-of-office BP measurements <130/80 mm Hg

Exclusion of end-organ damageNo evidence of end-organ damage required for definition

Suspected masked hypertension

Office rangeAverage office BP 120–129 mm Hg systolic or 75–79 mm Hg diastolic on 2 separate visits with ≥2 measurements each

Out-of-office confirmationAt least 2 out-of-office BP measurements ≥130/80 mm Hg

Supporting Codes and Cross-References

BLOOD PRESSURE MONITORS - ICD-10 supporting codesICD-10

I10	Essential (primary) hypertension
I11.0-I11.9	Hypertensive heart disease
I12.0-I12.9	Hypertensive chronic kidney disease
I13.0-I13.2	Hypertensive heart and chronic kidney disease
I15.0-I15.9	Secondary hypertension
I67.4	Hypertensive encephalopathy
I95.0-I95.9	Hypotension
I97.3	Post procedural hypertension
O10.011-O10.93	Pre-existing essential hypertension complicating pregnancy
O11.1-O11.9	Pre-existing hypertension with pre-eclampsia

1–10 of 18

1/2

BLOOD PRESSURE MONITORS - HCPCSHCPCSCovered

A4660	Sphygmomanometer/blood pressure apparatus with cuff and stethoscope (covered for Medicaid only)
A4663	Blood pressure cuff only (covered for Medicaid only)
A4670	Automatic blood pressure monitor

AMBULATORY BLOOD PRESSURE MONITORING - CPT/HCPCSCPTCovered

93784	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; including recording, scanning analysis, interpretation and report
93786	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; recording only.
93788	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; scanning analysis with report
93790	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; review with interpretation and report

Policy Revision History

2026-03-01Effective dateLatest

Policy effective date updated to 2026-03-01; material change noted removing the restriction that only devices approved by Priority Health will be covered (HBPM policy language revised).

2026-02-01Literature/guideline update

Policy references and aligns with recently published guideline and literature updates through February 2026, including multiple society guidelines and regulatory documents cited in the references section.

2024-12-18