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| Medical Policy: | X-24-044 |
| Topic: | Bone Mineral Density Studies |
| Section: | Radiology |
| Effective Date: | October 1, 2016 |
| Issue Date: | October 3, 2016 |
| Last Reviewed: | July 2016 |
Bone density studies measure how strong bones are. Healthcare providers use these test to both screen for and diagnose osteoporosis. The tests are also important in monitoring response to osteoporosis treatment, with the goal of reducing the risk of fracture. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
There are several different types of bone density test.
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 is non- invasive and provides precise measurements of bone density with minimal radiation.
Quantitative computerized tomography — this is a type of computed tomography (CT) that provides accurate measures of bone density in the spine.
Peripheral Bone Density testing — this is a portable device that can determine BMD at peripheral sites such as the radius, phalanges, or calcaneus.
Single Photon Absorptiometry (SPA) using the distal radius (wrist) and radiographic absorptiometry are other methods not widely used to determine bone mineral density.
Frequency Guidelines
Coverage for eligible bone density studies is limited to one test every 365 days 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 365 day 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 according to the preventive scheduled published annually. (Refer to the member's individual benefits for coverage information on this service.)
General Coverage Guidelines
Bone density studies are most commonly used in the evaluation of osteoporosis. 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.
Single Photon Absorptiometry (SPA) and radiographic absorptiometry (e.g., photodensitometry, radiogrammetry) are considered not medically necessary.
| Place of Service: Outpatient |
Bone Mineral Density Studies are typically outpatient procedures which are only eligible for coverage as inpatient procedures in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| FEP Guidelines |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider cannot bill the member for the non-covered service.
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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