Description

Bone mineral density (BMD) testing is a widely available clinical tool for screening and diagnosing osteoporosis.  These studies are also used to predict fracture risk and monitor response to therapy.  Bone mineral density can be measured using different techniques in a variety of central (ie, hip or spine) or peripheral (ie, wrist, finger, heel) sites.

The following technologies are most commonly used to measure BMD.

Dual-energy X-ray Absorptiometry — (DXA) is recommended by the National Osteoporosis Foundation (NOF) for bone density test of the spine, hips and pelvis to diagnose osteoporosis. When testing can’t be done on the spine, hips and pelvis, NOF suggests a central DXA test of the radius bone in the forearm. DXA can also be used to measure peripheral sites, such as the wrist and finger. DXA is non- invasive and provides precise measurements of bone density with minimal radiation.

Quantitative Computerized Tomography — (QCT) is a type of computed tomography (CT) that provides accurate measures of bone density in the spine. Compared with DXA, QCT is less readily available and associated with relatively high radiation exposure.

 Portable Peripheral Bone Density testing — portable devices that can determine BMD at peripheral sites such as the radius, phalanges, or calcaneus.

Single Photon Absorptiometry (SPA) and Dual-Photon Absorptiometry (DPA) — measure bone mineral content at the distal radius (SPA) and the spine and hip (DPA) using photons emitted at low energy levels.

Criteria

Frequency Guidelines

Coverage for eligible bone density studies is limited to one 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 patient (defined as a patient with a BMI of 35 or greater) when the patient'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 is not one that meets the expanded criteria described above, it will be denied as not medically necessary. 

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. (Refer to the member's individual benefits for coverage information on this service.) 

General Coverage Guidelines
Bone density studies may be considered medically necessary for ANY ONE of the following indications: 

• The patient is on long term steroid therapy (3 month duration or longer with a dosage of 5 mg per day of prednisone, or equivalent); or
• The patient is on long term anticonvulsant therapy (e.g. Phenytoin, Dilantin) (3 month duration or longer). It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation; or
• To determine if significant osteoporosis is present when associated with vertebral abnormalities on x-ray (such as 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. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation; or
• To monitor and evaluate response to ongoing restorative treatment (e.g., Fosamax) for patients with documented osteoporosis; or
• The patient suffers from one of the following calcium-wasting endocrinopathies: 
  • Cushing's Syndrome 
  • Hyperparathyroidism 
  • Hyperthyroidism 
  • Hypogonadism (except for uncomplicated, naturally occurring, or surgically induced post-menopausal clinical cases) 
  • Prolactinoma 
  • Celiac Sprue; or
• The patient has prostate cancer with androgen deprivation. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation; or
• Eating disorders, including anorexia nervosa and bulimia; or
• Breast cancer patients 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

DXA for Pediatrics (until age 19) may be considered medically necessary: 

• For the pediatric patient who is immobilized long term. 
• For the pediatric patient who has completed chemotherapy two 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 for all other indications are considered not medically necessary.

Procedure Codes

Single Photon Absorptiometry (SPA), Dual-Photon Absorptiometry (DPA), and radiographic absorptiometry (e.g., photodensitometry, radiogrammetry) are considered not medically necessary.

Procedure Codes

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 77078, 77080, and 77081

Payment For An Additional Bone Density Study Within The One (1) Every Two (2) Years Frequency Limitation For The Following Diagnosis Codes:

Links

References (PDF)