Description:
Brain natriuretic peptide (BNP) is a 32 amino acid polypeptide that contains a 17 amino acid ring structure common to all natriuretic peptides. It is classified as a cardiac neurohormone that is secreted by the ventricles of the heart in response to volume expansion and pressure overload. This circulating peptide has been used as a marker to assist in the diagnosis of congestive heart failure. Measurement of BNP is a highly sensitive and moderately specific method of differentiating heart failure from other non-cardiac causes of dyspnea, such as pulmonary disease.

Policy:
Benefits are considered MEDICALLY NECESSARY for the following indications:

• BNP measurements are used to distinguish cardiac cause of acute dyspnea from pulmonary or other non-cardiac causes in the urgent care setting.
• Distinguishing decompensated congestive heart failure (CHF) from exacerbated chronic obstructive pulmonary disease (COPD) in a symptomatic patient with combined CHF and COPD.

Benefits are NOT COVERED OR CONSIDERED MEDICALLY NECESSARY for the following indications:

• Routine diagnosis of heart failure
• Management of heart failure
• Diagnosis of other cardiac conditions (e.g., left ventricular dysfunction, ventricular septal defect, coronary artery disease)

Serial measurements of plasma BNP and/or its inactive metabolite (NT-proBNP) are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY for the following:

• Titrating therapy for members with chronic heart failure
• Monitoring the effectiveness of therapy for members with congestive heart failure
• Determining prognosis of members after an acute coronary syndrome episode
• Determining prognosis of member with chronic heart failure
• For guiding the initiation of thrombolytic therapy in members with acute pulmonary embolism
• For guiding statin decisions for members with heart failure
• For screening unrecognized left ventricular dysfunction
• For managing (diagnostic, prognostic and therapeutic) members with chronic renal failure
• For routine evaluation of dyspnea, other than where necessary to distinguish heart failure from pulmonary disease

• Natriuretic peptide levels may be influenced by several patient factors, including age, sex, renal function, thyroid function, anemia and body habitus. Importantly, obese persons tend to have lower natriuretic peptide levels than do non-obese persons.
• Natriuretic peptide levels should not replace standard clinical assessment tools, such as echocardiography (Class III recommendation).
• Normal BNP and NT-proBNP ranges vary according to the assay used and the characteristics of the control population. The assay commonly used for research produces systematically lower measurements than do commercial assays.
• The committee made only one Class I recommendation for the clinical use of natriuretic peptides: to exclude or confirm the diagnosis of HF in patients with ambiguous signs and symptoms in the acute setting. Such an application in the non-acute setting received a Class IIa recommendation for lack of studies.
• The routine use of natriuretic peptides in the initial evaluation of patients with suspected HF, for guiding therapy in patients with established HF and for screening purposes is also discouraged (Class III recommendations).

Thus, available data support relatively few strong recommendations for the clinical use of natriuretic peptide measurements in patients with HF, other than adjunctive use for diagnosis in the acute care setting. Until more evidence is available on how these cardiac biomarkers should be integrated into clinical care, their routine use in the diagnosis, treatment and screening of HF is not warranted.

References:

1. Bayes-Genis A, Santalo-Bel M, Zapico-Muniz E, Lopez L, Cotes C, Bellido J, et al. N-terminal probrainnatriuretic peptide (NT-proBNP) in the emergency diagnosis and in-hospital monitoring of patient with          dyspnoea and ventricular dysfunction. Eur J Heart Fail. 2004 Jun; 6(3): 301-8.
2. de Denus S, Pharand C, Williamson DR. Brain natriuretic peptide in the management of heart failure:  The versatile neurohormone. Chest. 2004; 125(2): 652-668. 
3. Galvani M, Ferrini D, Ottani F, Natriuretic peptides for risk stratification of patients with acute coronary syndromes. Eur J Heart Fail. 2004 Jun; six (3): 327-33.
4. Hartmann F, Packer M, Coats AJ, Fowler MB, Krum H, Mohacsi P, et al.  NT-proBNP in severe chronic heart failure: rationale, design and preliminary results of the COPERNICUS NT-proBNP substudy.  Eur J Heart Fail. 2004 Jun 6(3): 343-50.
5. HAYES Medical Technology Directory.  Brain Natriuretic Peptide Test for Diagnosis of Congestive Heart Failure.  Lansdale, PA: HAYES, Inc.; ©2001 Winifred S. Hayes, Inc.  Originally published 2001 Oct.  Updated 2004 Apr 27.
6. Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS, et al., ACC/AHA guide
7. Maisel AS, Zoorob R. B-type natriuretic peptide in congestive heart failure-diagnosis and management.  American Academy of Family Physicians.  Updated 2004 Mar.  Accessed May 31, 2005.  
8. Wu AH, Smith A. Biological variation of the natriuretic peptides and their role in monitoring patients with heart failure.  Eur J Heart Fail. 2004; 6(3): 355-358.
9. Davenport C, Cheng EY, Kwok YT, et al. Assessing the diagnostic test accuracy of natriuretic peptides and ECG in the diagnosis of left ventricular systolic dysfunction: A systematic review and meta-analysis. Br J Gen Pract. 2006;56(522):48-56.
10. Body R, Roberts C. Best evidence topic report. Brain natriuretic peptide as a potential marker of acute coronary syndromes. Emerg Med J. 2006;23(5):403-407.
11. Sohne M, Ten Wolde M, Boomsma F, et al. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. 2006;4(3):552-556.
12. Pfisterer M, Buser P, Rickli H, et al; TIME-CHF Investigators. BNP-guided vs symptom-guided heart failure therapy: The Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) randomized trial. JAMA. 2009;301(4):383-392.
13. Schneider HG, Lam L, Lokuge A, et al. B-type natriuretic peptide testing, clinical outcomes, and health services use in emergency department patients with dyspnea: A randomized trial. Ann Intern Med. 2009;150(6):365-371.
14. Gallegos PJ, Maclaughlin EJ, Haase KK. Serial monitoring of brain natriuretic peptide concentrations for drug therapy management in patients with chronic heart failure. Pharmacotherapy. 2008;28(3):343-355.
15. Rottlaender D, Michels G, Hoppe UC. Natriuretic peptides--when should they be used in heart failure? Dtsch Med Wochenschr. 2008;133(5):196-200.
16. Institute for Clinical Systems Improvement (ICSI). B-type natriuretic peptide (BNP) for the diagnosis and management of congestive heart failure. ICSI Technology Assessment. TA# 091. Bloomington, MN: ICSI; August 2005.
17. Tang WH, Francis GS, Morrow DA, et al; National Academy of Clinical Biochemistry Laboratory Medicine. National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines: Clinical utilization of cardiac biomarker testing in heart failure. Circulation. 2007;116(5):e99-e109.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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