Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Bone density studies are used for preventive screening in post-menopausal women who may be at risk for bone fractures caused by a decrease in bone density.  Bone density testing is used to medically monitor patients being treated for conditions that can decrease bone density and increase risk for bone fractures

1)    Bone density screening is covered under Preventive Care Benefits every two or more years by QualChoice:

a)    In women age 65 and over,

b)    In women age 55-64 if there is a specific diagnosis associated with decreased bone density and increased risk for bone fractures

2)    Bone density testing is covered under the Medical Benefit every three or more years by QualChoice:

a)    in women age 30-54 to monitor specific diagnoses that can decrease bone density and increase risk for bone fractures

b)    in men age 30 and older to monitor specific diagnoses that can decrease bone density and increase risk for bone fractures

3)    Bone density testing is covered under the Medical Benefit every two or more years by QualChoice:

a)    In members age 30 and older being treated for osteoporosis with or without fractures.

4)    Bone density testing requires prior authorization for all members under age 30.

Bone density measurement is a tool that can be used for routine preventive screening in groups at high risk of osteoporosis (every 2 years), for disease management in groups at moderate risk for osteoporosis (every 3 years) or for monitoring treatment in patients with known osteoporosis (every 2 years).                                                                                                   

1)    Bone density measurement for routine screening purposes is covered under the Preventive Benefit:

a)    For women 65 years or older every two (2) years or longer.

b)    In women ages of 55 – 64 years with a diagnosis of hyperthyroidism, hyperparathyroidism, severe malnutrition, intestinal malabsorption, bedridden, long-term systemic steroid use, prolonged BMI < 19 or any pathologic fracture as a screening test under the Preventive Benefit every two (2) years. See BI062.

2)    Bone density measurement for disease management purposes is covered under the Medical Benefit:

a)    In women age 30 – 64 or men age ≥ 30 or more who have a medical indication that would suggest increased risk of osteoporosis, as a diagnostic test under the Medical Benefit every three (3) years or longer. If such an indication can be indicated on the claim with an appropriate ICD-10 diagnosis code, it should be so indicated. All cases may be reviewed prior to payment; if substantiating diagnosis is available, the claim will be paid without further investigation but if such information is not available, medical records may be requested. Potential indications for such a study would include:

                      i.        A QFracture calculated 10 year osteoporotic fracture risk of 9% or greater, or a calculated 10 year osteoporotic hip fracture risk of 2% or greater.(See: http://www.qfracture.org); or

                    ii.        A S.C.O.R.E. of 6 or higher (see: http://osteoed.org/tools.php?type=score); or

                   iii.        A WHO FRAX® calculated risk of 9% or greater; (see http://www.shef.ac.uk/FRAX/tool.jsp); or

                   iv.        Prolonged use of high doses of corticosteroids (Z79.52) (doses >7 mg/day of prednisone or the equivalent for more than 3 months); or

                    v.        Prolonged bed rest (Z74.01) exceeding 90 days of non-weight bearing; or

                   vi.        Starvation (E40 – E42, E43); or

                  vii.        A prolonged period with BMI below 19 (Z68.1); or

                 viii.        Hypogonadism without hormonal replacement of prolonged duration; or

                   ix.        Primary hyperparathyroidism (E21.0 – E21.5); or

                    x.        Women with hyperthyroidism (E05.00 – E05.91); or

                   xi.        Women on long-term anti-convulsant therapy (e.g., Phenytoin or Phenobarbital); or

                  xii.        Intestinal malabsorption (K90.0-K90.9); or

                 xiii.        Men with hypogonadism or receiving androgen deprivation treatment (E89.5 – Post ablative testicular hypofunction) (e.g., Leuprolide or Goserelin); or

                xiv.        The occurrence of multiple fractures with minimal trauma such as compression fractures documented by x-ray; or

                  xv.        The occurrence of pathologic fractures without other apparent cause:

1)    Bone density measurement for monitoring osteoporosis treatment under the Medical Benefit:

a)    Bone Density measurement may be indicated for the monitoring of changes in 

bone density for a person who is receiving treatment for an established diagnosis of osteoporosis (Tscore <-2.5) with or without pathologic fractures. This testing will be allowed every two (2) years. 

2)    In members under age 30, bone density testing requires pre-authorization.

Codes Used In This BI:

76977   US bone density measure

77080   DXA bone density axial

77081   DXA bone density/peripheral

77085   DXA with vertebral fracture assessment

77086   Vertebral fracture assessment via (DXA)

0547T   Bone-material quality testing by microindentation(s) of the tibia(s), with results reported as a score

0554T   Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, retrieval and transmission of the scan data, assessment of bone

0555T   Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan, retrieval and transmission of the scan data

0556T   Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan, assessment of bone strength and fracture risk and bone mineral density

0557T   Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan, interpretation and report

1)    Bone mass measurement by dual photon absorptiometry (DPA) or ultrasound is considered experimental and investigational.

2)    Screening/evaluation of vertebral fractures with dual energy x-ray absorptiometry (DEXA or DXA, 77085 or 77086) (also known as morphometric x-ray absorptiometry) as an adjunct to bone mineral density measurement is considered experimental and investigational.  There is a lack of clinical trial evidence showing that patients with vertebral fractures on DXA but with bone mineral density levels above treatment thresholds benefit from pharmacologic treatment (BCBSA, 2004; BCBSA, 2005).  Note: Examples of vertebral fracture assessment application packages that have received 510(k) marketing clearance are the Instant Vertebral Assessment (IVA) (Hologic, Inc.) and Dual Energy Vertebral Assessment (DVA) (previously known as Lateral Vertebral Assessment (LVA) (GE Lunar Medical Systems). 

3)    Bone-material quality testing by microindentation (0547T) is considered experimental and investigational

4)    Bone strength & fracture risk using finite element analysis of functional data (0554T – 0557T) are considered experimental and investigational

5)    Bone density testing frequency:

a)    For women over the age of 65 or 55 – 64 at increased risk, every two (2) years (preventive).

b)    For women or men with an established diagnosis of osteoporosis (M81.0, M81.8) every two (2) years (medical).

c)    For any other indication, every three (3) years (medical).

1)    WHO fracture risk assessment tool at: http://www.sheffield.ac.uk/FRAX/index.jsp

2)    U.S. Preventive Services Task Force. Screening for osteoporosis in postmenopausal women. In: Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 3rd ed. Rockville, MD: Agency for Healthcare Research and Quality; 2000-2002. Available at: http://www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm

3)    International Society of Clinical Densitometry (ISCD). Bone mineral density testing. Official Positions. West Hartford, CT: ISCD; November 1, 2003. http://www.iscd.org/Visitors/positions/official.cfm?CFID=7651444&CFTOKEN=80107394&jsessionid=f030c4945ff59431709d4d6a113b464e7624

4)    Miller PD. Bone mass measurements. Clin Geriatr Med. 2003; 19(2):281-297, vi.

5)    BlueCross BlueShield Association (BCBSA), Technology Evaluation Center (TEC). Screening for vertebral fracture with dual x-ray absorptiometry. Available at: http://www.bcbs.com/betterknowledge/tec/vols/20/20_14.html

6)    Arkansas BlueCross BlueShield, Coverage Policy Manual; Bone mineral density study. Available at: http://www.arkansasbluecross.com/members/report.aspx?policyNumber=1997054

7)    Osteo ed.org Simple Calculated Osteoporosis Risk Estimation (SCORE) at : http://osteoed.org/tools.php?type=score

8)    American Physician; diagnosis and treatment of osteoporosis at : http://www.aafp.org/afp/20090201/193.html

9)    Erlichman M, Holohan T. Bone densitometry. In Nuclear Medicine: Diagnosis and Therapy. Harbert, Eckelman, Neurnann, eds. New York, NY: Thieme Medical Publishers, Inc.; 1996: 865-880.

10) Gourlay ML, et al. Bone-Density Testing Interval and Transition to Osteoporosis in Older Women.  NEJM 2012; 366:54-63.