The following bone mineral density studies are those most commonly used in the evaluation of osteoporosis, sometimes referred to as osteopenia. This condition might be the result of alcoholism, hyperparathyroidism, malabsorption, chronic renal disease, Cushing's syndrome, etc.

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 method. Eligible bone density studies exceeding this frequency are considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

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.) Routine conditions for this test include, but are not limited to, age-related menopause and surgically-induced menopause (e.g., following oophorectomy).

Bone biopsy (code 20220) provides a qualitative measurement of the bone mineral of trabecular bone and is used primarily to differentiate osteomalacia from osteoporosis.

Dual Energy X-ray Absorptiometry (DEXA)(codes 77080, 77081) is a two-dimensional projection system similar to DPA except that it uses an x-ray tube for its photon source rather than a radioisotope. DEXA is most commonly used to measure bone mineral of the hip and spine, but measurements may also be taken of the forearm, calcaneus, or the total body.

Dual Photon Absorptiometry (DPA)(code 78351)  is a modification of the single-energy technique using a radioisotope that emits photons at two different energy levels. This method measures the total integrated mineral in the path of the beam.

Quantitative Computed Tomography (QCT)(codes 77078, 77079) measures cancellous bone, cortical bone, or an integrated sum of both. The method can identify the absolute mineral content of a specific volume of bone.

Bone density studies performed using one of  the above methods are eligible for the following indications:

• The patient is on long term steroid therapy (3 month duration or longer with a dosage of 7.5 mg per day of prednisone, or equivalent)(V58.65);
• The patient is on long term phenytoin (e.g., Dilantin) therapy. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation;
• To determine if significant osteoporosis is present when associated with vertebral abnormalities on x-ray (such as compression fractures) or radiographic evidence of osteopenia (733.90);
• Fractures of the hip, wrist, or spine in the absence of appropriate severe trauma (733.12, 733.13, 733.14);
• 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;
• To monitor and evaluate response to ongoing restorative treatment (e.g., Fosamax) for patients with documented osteoporosis (733.00, 733.01, 733.02, 733.03, 733.09);
• The patient suffers from one of the following calcium-wasting endocrinopathies:
  
  • Cushing's Syndrome (255.0)
  • Hyperparathyroidism (252.00, 252.01, 252.02, 252.08)
  • Hyperthyroidism (242.00-242.91)
  • Hypogonadism (256.39, 257.1, 257.2)(except for uncomplicated, naturally occurring, or surgically induced post-menopausal clinical cases)
  • Prolactinoma (194.3, 227.3, 237.0, 239.7)
  • Celiac Sprue (579.0)
• 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;
• Post ablative ovarian failure (256.2);
• Breast cancer patients who are on aromatase inhibitors (V07.52). It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

Single Energy X-ray Absorptiometry (SEXA)(code G0130) and bone sonometry (code 76977) are methods that are considered screening in nature.

Single Photon Absorptiometry (SPA)(code 78350) and radiographic absorptiometry (e.g., photodensitometry, radiogrammetry)(code 77083) are methods that are not generally accepted by the medical community as clinically useful in diagnosing or treatment. As such, they are considered not medically necessary and are not eligible for payment.

For information on zoledronic acid (Reclast®, Zometa®), refer to Medical Policy Bulletin I-42.

For information on ibandronate sodium (Boniva®), refer to Medical Policy Bulletin I-95.

NOTE:

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.

FEP covers bone density tests, both screening and diagnostic.

PRN References

04/1995, Bone mineral density studies
12/1996, Bone mineral density studies
02/2000, Technology for assessing bone density considered screening
02/2005, Screening bone density studies eligible according to benefits
06/2007, New indications for coverage for bone mineral density studies

The Challenges of Peripheral Bone Density Testing - Which Patients Need Additional Central Density Skeletal Measurements?, Journal of Clinical Densitometry, Vol. 1, No. 3, Fall 1998

Stiffness in Discrimination of Patients with Vertebral Fractures, Osteoporosis International, Vol. 9, 1999