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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2008 Title: Bone Mineral Density Studies
Revision Date: 11/01/2019 Document: BI216:00
CPT Code(s): 76977, 77080, 77081, 77085, 77086, 0547T, 0554T, 0555T, 0556T, 0557T
Public Statement

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.

 


Medical Statement

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:

M84.40XA M84.411A M80.871D M80.872D M80.879D M80.88XD M84.40XD M84.411D M80.871G M80.872G M80.879G M80.88XG M84.40XG M84.411G M80.871K M80.872K M80.879K M80.88XK M84.40XK M84.411K M80.871P M80.872P M80.879P M80.88XP M84.40XP M84.411P M80.871S M80.872S M80.879S M80.88XS M84.40XS M84.411S M84.412A M84.419A M84.421A M84.422A M84.429A M84.431A M84.412D M84.419D M84.421D M84.422D M84.429D M84.431D M84.412G M84.419G M84.421G M84.422G M84.429G M84.431G M84.412K M84.419K M84.421K M84.422K M84.429K M84.431K M84.412P M84.419P M84.421P M84.422P M84.429P M84.431P M84.412S M84.419S M84.421S M84.422S M84.429S M84.431S M84.432A M84.433A M84.434A M84.439A M84.441A M84.442A M84.432D M84.433D M84.434D M84.439D M84.441D M84.442D M84.432G M84.433G M84.434G M84.439G M84.441G M84.442G M84.432K M84.433K M84.434K M84.439K M84.441K M84.442K M84.432P M84.433P M84.434P M84.439P M84.441P M84.442P M84.432S M84.433S M84.434S M84.439S M84.441S M84.442S M84.443A M84.444A M84.445A M84.446A M84.451A M84.452A M84.443D M84.444D M84.445D M84.446D M84.451D M84.452D M84.443G M84.444G M84.445G M84.446G M84.451G M84.452G M84.443K M84.444K M84.445K M84.446K M84.451K M84.452K M84.443P M84.444P M84.445P M84.446P M84.451P M84.452P M84.443S M84.444S M84.445S M84.446S M84.451S M84.452S M84.453A M84.454A M84.459A M84.461A M84.462A M84.463A M84.453D M84.454D M84.459D M84.461D M84.462D M84.463D M84.453G M84.454G M84.459G M84.461G M84.462G M84.463G M84.453K M84.454K M84.459K M84.461K M84.462K M84.463K M84.453P M84.454P M84.459P M84.461P M84.462P M84.463P M84.453S M84.454S M84.459S M84.461S M84.462S M84.463S M84.464A M84.469A M84.471A M84.472A M84.473A M84.474A M84.464D M84.469D M84.471D M84.472D M84.473D M84.474D M84.464G M84.469G M84.471G M84.472G M84.473G M84.474G M84.464K M84.469K M84.471K M84.472K M84.473K M84.474K M84.464P M84.469P M84.471P M84.472P M84.473P M84.474P M84.464S M84.469S M84.471S M84.472S M84.473S M84.474S M84.475A M84.476A M84.477A M84.478A M84.479A M84.48XA M84.475D M84.476D M84.477D M84.478D M84.479D M84.48XD M84.475G M84.476G M84.477G M84.478G M84.479G M84.48XG M84.475K M84.476K M84.477K M84.478K M84.479K M84.48XK M84.475P M84.476P M84.477P M84.478P M84.479P M84.48XP M84.475S M84.476S M84.477S M84.478S M84.479S M84.48XS

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


Limits

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).


Background

1)    The following methods have been used as bone mass measurements of the axial or appendicular (peripheral) skeleton:

a)    Dual energy X-ray absorptiometry (DEXA or DXA);

b)    Single energy X-ray absorptiometry (SEXA);

c)     Single photon absorptiometry (SPA);

d)    Radiographic absorptiometry (photodensitometry);

e)    Quantitative computed tomography (QCT);

f)      Ultrasound bone mineral density studies (e.g., Sahara, SoundScan, Achilles + Bone Sonometer).

2)    DEXA has become the standard of care because of its accuracy, usefulness for measuring bone density at the highest risk sites (vertebra, hip), low radiation exposure, and low cost. 

3)    The QFracture risk score developed by the University of Nottingham is a validated tool designed to predict the fracture risk based on a number of different factors, including age, smoking status, BMI, presence of risk increasing diseases such as rheumatoid arthritis, and use of certain medications.  It may be used in men or women age 30-84 that have not had a previous osteoporotic fracture.

4)    Simple Calculated Osteoporosis Risk Estimation (S.C.O.R.E.) is a validated tool designed to predict postmenopausal women who are likely to have a T-score < -2 and should have screening performed. This tool was developed by the University of Washington School of Medicine (see: http://osteoed.org/tools.php?type=score).

5)    Some authorities have advocated annual bone mineral density screening.  The International Society for Clinical Densitometry, an association of providers with an interest in bone density measurement, recommends annual testing to detect continued bone loss in patients receiving treatment.  The position statement included a series of recommendations, but did not provide analysis to support these recommendations.  In addition, the American College of Radiology has recommended annual testing in patients receiving treatment.  However, the clinical literature on the accuracy and precision of bone density measurement does not support a recommendation for annual screening.  Erlichman & Holohan (1996) reviewed the literature on commonly used bone densitometry techniques, including DEXA.  They found that, although reviews of recent studies report DEXA accuracy error from 3 to 6 percent, other data indicate that DEXA accuracy error of ashed bone specimens of 9 percent.  (Measurements obtained by densitometers are compared with an independent standard measurement of bone mass, such as ashed bone sections.  The accuracy error is determined by how much the measurement varies from this accepted or "true" value.)  DEXA scans of the femur have a precision error from 0.5 percent to 3 percent.  Precision error is the variability in the measurements occurring with repeated measurements of the same object.  A technique`s precision is critical for serial measurements that correctly document bone loss over time.  Factors such as patient positioning, calibration and standardization procedures and differences in operator technique can result in large measurement variations.  The precision of measurements is reduced outside of the controlled conditions of a clinical trial setting.  The requisite minimum intervals between measurements that are necessary to reliably detect a reduction in bone mass are related to the precision attainable with current instruments and the rate of bone mass loss, assuming that the accuracy of the instrument is invariable.  If one assumed a 1 percent precision error, an annual rate of bone loss of 3 percent would be required to reliably detect bone mass loss after 1 year.  But Erlichman & Holohan (1996) explained that it is unlikely that yearly densitometry would be clinically indicated given the fact that 1 percent precision error is rarely attained and that a 3 percent annual loss in bone mass would be distinctly uncommon.  Precision errors in the range of 2 to 3 percent and annual bone mass losses of 1 to 2 percent are parameters more representative of published data.  In those instances, the minimum interval between densitometry measures necessary to document bone mass loss would be between 3.7 and 6 years.  Furthermore, there are no clinical data that demonstrate improved outcomes in osteoporosis patients who are screened annually.  Clinical trials of the bisphosphonate alendronates for the treatment of osteoporosis have found that failure to respond to therapy is a rare event.


Reference

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.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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