B-Type Natriuretic Peptide (BNP)

Jurisdiction: J9 MAC Part B. States: Florida, Puerto Rico, US Virgin Islands. Type: Active LCD

History/Background and/or General Information Congestive Heart Failure (CHF) is characterized by a progressive activation of the neurohormonal systems that control vasoconstriction and sodium retention; the activation of these systems plays a role in its pathogenesis and progression. As the heart fails, B-Type Natriuretic Peptide (BNP), a cardiac neurohormone is secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. Used in conjunction with other clinical information, rapid measurement of BNP is useful in establishing or excluding the diagnosis and assessment of severity of CHF in patients with acute dyspnea so that appropriate and timely treatment can be initiated. This test is also used to predict the long-term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute coronary event. For the purposes of this LCD, the total and N terminal assays are both acceptable. Covered Indications B-Type Natriuretic Peptide (BNP) measurements will be considered medically reasonable and necessary to establish or exclude the diagnosis and assessment of severity of CHF in patients with acute dyspnea when used in combination with other medical data such as medical history, physical examination, laboratory studies, chest x-ray, and electrocardiography (ECG). Rapid measurement of BNP concentration in the blood appears to be a sensitive and specific test for differentiating patients with CHF from primary pulmonary causes of dyspnea in acute care settings. Plasma BNP levels are significantly increased in CHF patients with or without concurrent lung disease compared with patients with primary lung disease. Plasma BNP levels are significantly increased in CHF patients presenting with acute dyspnea compared with patients presenting with acute dyspnea due to other causes. BNP levels are also useful for risk stratification (to assess risk of death, myocardial infarction or congestive heart failure) among patients with acute coronary syndrome (myocardial infarction with or without T-wave elevation and unstable angina). Limitations BNP measurements must be analyzed in conjunction with standard diagnostic tests, the medical history, and clinical findings; its efficacy as a stand-alone test has not yet been established. Additional investigation is required to further define the diagnostic value of plasma BNP in monitoring the efficiency of treatment for CHF and in tailoring the therapy for heart failure. Therefore, BNP measurements for monitoring and management of CHF are not a covered service. Generally, it is not expected that this test would be performed more than four times in a year. BNP measurements are not a covered service when performed as a routine screening procedure, in the absence of documentation of clinical findings in the patient’s medical record indicating suspected CHF, or for monitoring and management of CHF. As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual , Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.