Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Routine Bone Density Studies
Routine bone density studies performed as a screening test for osteoporosis are eligible for members with coverage for Preventive Health services according to the preventive scheduled published annually. (Refer to the member's individual benefits for coverage information on this service.)
Frequency Guidelines
Coverage for eligible bone density studies is limited to one (1) test every two (2) years from the date of the previous bone density study, regardless of the anatomic area tested or imaging modality used to perform the study. However, more frequent bone mass measurements may be considered medically necessary under the following circumstances:
-
To allow simultaneous axial (spine, hips, pelvis) and peripheral (forearm, radius, wrist) bone density testing for hyperparathyroidism;
or
-
To allow peripheral (forearm, radius, wrist) bone density testing in lieu of the axial skeleton (spine, hips, pelvis) in the very obese individual (defined as an individual with a BMI of 35 or greater) when the individual's weight exceeds the weight limit for the DXA table;
or
- To allow peripheral (forearm, radius, wrist) bone density testing when the hips or spine cannot be measured or interpreted because of severe arthritis and/or previous surgery.
When a bone density study is reported with a diagnosis code that is covered under the 'general coverage' criteria, but the service falls within the two (2) years frequency limitation and the diagnosis or condition not meeting the expanded criteria described above, it will be denied as not medically necessary.
General Coverage Guidelines
Bone density studies may be considered medically necessary for
ANY ONE
of the following indications:
-
Women age 65 and older;
or
-
Men age 70 and older;
or
-
Post-menopausal individuals above age 50-69, based of risk factor profile;
or
-
Post-menopausal individuals age 50 and older who have had an adult age fracture, to diagnoses and determine degree of osteoporosis;
or
-
The individual is on long term steroid therapy three (3) month duration or longer with a dosage of five (5) mg per day of prednisone, or equivalent;
or
-
The individual is on long term anticonvulsant therapy (i.e., Phenytoin, Dilantin) three (3) month duration or longer;
or
-
To determine if significant osteoporosis is present when associated with vertebral abnormalities on x-ray (i.e., compression fractures) or radiographic evidence of osteopenia;
or
-
Fractures of the hip, wrist, or spine in the absence of appropriate severe trauma;
or
-
Documented loss of height of 1.5 inches or greater;
or
-
To monitor and evaluate response to ongoing restorative treatment (i.e., Fosamax) for individuals with documented osteoporosis;
or
-
The individual suffers from one of the following calcium-wasting endocrinopathies:
-
Cushing's Syndrome;
or
-
Hyperparathyroidism;
or
-
Hyperthyroidism;
or
-
Hypogonadism (except for uncomplicated, naturally occurring, or surgically induced post-menopausal clinical cases);
or
-
Prolactinoma;
or
-
Celiac Sprue;
or
-
The individual has prostate cancer with androgen deprivation;
or
-
Eating disorders, including anorexia nervosa and bulimia;
or
- Breast cancer individuals who are on aromatase inhibitors.
DXA for pediatrics (until age 19) may be considered medically necessary when
ANY ONE
of the following is met:
-
Prolonged use of glucocorticoid or corticosteroid therapy;
or
-
Chronic inflammatory disease;
or
-
Hypogonadism;
or
-
Idiopathic juvenile osteoporosis;
or
-
Long term immobilization;
or
-
Osteogenesis imperfecta;
or
- Completion of chemotherapy two (2) years prior to ordering DXA.
The provider must submit medical records and/or additional documentation to determine coverage in the above situations.
Bone density studies not meeting the criteria as indicated in this policy are considered not medically necessary.
Procedure Codes
| 77078 | 77080 | 77081 | 77089 | 77090 | 77091 | 77092 |
