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Bone Mineral Density Studies

Section: Radiology
Effective Date: July 01, 2018
Revised Date: July 31, 2019
Last Reviewed: July 16, 2019

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

77078  77080  77081 

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

Procedure Codes

78350  78351

Diagnosis Codes

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

C75.1  C75.2  D35.2  D35.3  D44.3  D44.4  D49.7 
E05.00  E05.01  E05.10  E05.11  E05.20  E05.21  E05.30 
E05.31  E05.40  E05.41  E05.80  E05.81  E05.90  E05.91 
E21.0  E21.1  E21.2  E21.3  E24.0  E24.2  E24.3 
E24.4  E24.8  E24.9  E28.39  E29.1  E74.20  E74.21 
E74.29  E89.40  E89.41  E89.5  F50.00  F50.01  F50.02 
F50.2  F50.81  F50.82  F50.89  K50.00  K50.011  K50.012 
K50.013  K50.014  K50.018  K50.019  K50.10  K50.111  K50.112 
K50.113  K50.114  K50.118  K50.119  K50.90  K50.911  K50.912 
K50.913  K50.914  K50.918  K50.919  K90.0  K90.49  K90.89 
K90.9  M48.50XA  M48.51XA  M48.52XA  M48.53XA  M48.54XA  M48.55XA 
M48.56XA  M48.57XA  M48.58XA  M80.00XA  M80.00XD  M80.011A  M80.011D 
M80.011G  M80.011K  M80.011P  M80.011S  M80.012A  M80.012D  M80.012G 
M80.012K  M80.012P  M80.012S  M80.021A  M80.021D  M80.021G  M80.021K 
M80.021P  M80.021S  M80.022A  M80.022D  M80.022G  M80.022K  M80.022P 
M80.022S  M80.031A  M80.031D  M80.031G  M80.031K  M80.031P  M80.031S 
M80.032A  M80.032D  M80.032G  M80.032K  M80.032P  M80.032S  M80.039A 
M80.041A  M80.041D  M80.041G  M80.041K  M80.041P  M80.041S  M80.042A 
M80.042D  M80.042G  M80.042K  M80.042P  M80.042S  M80.051A  M80.051D 
M80.051G  M80.051K  M80.051P  M80.051S  M80.052A  M80.052D  M80.052G 
M80.052K  M80.052P  M80.052S  M80.059A  M80.059D  M80.061A  M80.061D 
M80.061G  M80.061K  M80.061P  M80.061S  M80.062A  M80.062D  M80.062G 
M80.062K  M80.062P  M80.062S  M80.069A  M80.071A  M80.071D  M80.071G 
M80.071K  M80.071P  M80.071S  M80.072A  M80.072D  M80.072G  M80.072K 
M80.072P  M80.072S  M80.08XA  M80.08XD  M80.08XG  M80.08XK  M80.08XP 
M80.08XS  M80.80XS  M80.811A  M80.811D  M80.811G  M80.811K  M80.811P 
M80.811S  M80.812A  M80.812D  M80.812G  M80.812K  M80.812P  M80.812S 
M80.819P  M80.819S  M80.821A  M80.821D  M80.821G  M80.821K  M80.821P 
M80.821S  M80.822A  M80.822D  M80.822G  M80.822K  M80.822P  M80.822S 
M80.831A  M80.831D  M80.831G  M80.831K  M80.831P  M80.831S  M80.832A 
M80.832D  M80.832G  M80.832K  M80.832P  M80.832S  M80.839A  M80.841A 
M80.841D  M80.841G  M80.841K  M80.841P  M80.841S  M80.842A  M80.842D 
M80.842G  M80.842K  M80.842P  M80.842S  M80.851A  M80.851D  M80.851G 
M80.851K  M80.851P  M80.851S  M80.852A  M80.852D  M80.852G  M80.852K 
M80.852P  M80.852S  M80.859A  M80.859G  M80.861A  M80.861D  M80.861G 
M80.861K  M80.861P  M80.861S  M80.862A  M80.862D  M80.862G  M80.862K 
M80.862P  M80.862S  M80.871A  M80.871D  M80.871G  M80.871K  M80.871P 
M80.871S  M80.872A  M80.872D  M80.872G  M80.872K  M80.872P  M80.872S 
M80.88XA  M81.0  M81.6  M81.8  M84.431A  M84.432A  M84.433A 
M84.434A  M84.439A  M84.451A  M84.452A  M84.459A  M84.48XA  M84.531A 
M84.532A  M84.533A  M84.534A  M84.539A  M84.551A  M84.552A  M84.553A 
M84.559A  M84.58XA  M84.631A  M84.632A  M84.633A  M84.634A  M84.639A 
M84.651A  M84.652A  M84.653A  M84.659A  M84.68XA  M85.831  M85.832 
M85.841  M85.842  M85.85  M85.851  M85.852  M85.859  M85.86 
M85.861  M85.862  M85.869  M85.87  M85.871  M85.872  M85.879 
M85.88  M85.9  M85.89  M89.9  M94.9  Q78.0  R29.890 
R93.6  R93.7  Z78.0  Z79.51  Z79.52  Z79.811  Z92.21 
Z92.240  Z92.241

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

E21.0  E21.1  E21.2  E21.3  Z68.35  Z68.36  Z68.37 
Z68.38  Z68.39  Z68.41  Z68.42  Z68.43  Z68.44  Z68.45