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Medical Necessity of B-Type Natriuretic Peptide (BNP)

The purpose of this article is to provide education on medical necessity of B-Type Natriuretic Peptide (BNP) services in response to denials noted through the NAS Medical Review department. BNP is synthesized and released from the heart, and elevated levels may lend support to a diagnosis of abnormal ventricular function or hemodynamics. Used in conjunction with other clinical information, it may be reasonable to obtain BNP for patients presenting with non-distinguishing symptomology that may be attributed to either heart failure or pulmonary disease (e.g. Chronic Obstructive Pulmonary Disease). Similarly, measurement of BNP may be useful in the initial diagnosis of a non-obese, symptomatic or asymptomatic patient with suspected heart failure; primary left systolic heart failure. The BNP test is not medically necessary for the purpose of monitoring Congestive Heart Failure (CHF) or for monitoring the efficacy of CHF treatment. The test results have not been shown to alter treatment, otherwise improve condition, or add information beyond that of clinical exam in CHF patients. If BNP is obtained to assess risk in patients presenting with Acute Coronary Syndrome (ACS), accelerated or new-onset angina, or suspected ischemic condition, documentation must clearly demonstrate that BNP was useful in the active management of the patient, i.e., altered the treatment plan. If both an echocardiogram and BNP are ordered, documentation must clearly indicate the need for both examinations. As an echocardiogram is the definitive study for diagnosing heart failure, BNP is usually unnecessary. In addition, if the echocardiogram demonstrates normal or unchanged cardiac function, then it is not medically necessary to obtain BNP if not already ordered and for a clearly identified reason. Sources: Social Security Act (SSA) Section 1862(a)(1)(A); Internet Only Manual (IOM) Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 80.1; American College of Cardiology and American Heart Association (ACC/AHA) 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

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INDUSTRY NEWS TAGS: Noridian


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