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DESCRIPTIONBone mineral density (BMD) can be measured with a variety of techniques in a variety of central (i.e., hip or spine) or peripheral (i.e., wrist, finger, heel) sites. While BMD measurements are predictive of fragility fractures at all sites, central measurement of the hip and spine are the most predictive. Fractures of the hip and spine (i.e., vertebral fractures) are also considered to be the most clinically relevant.
There are multiple technologies for non-invasive measurement of bone content which are available. At the time of this writing they included dual energy X-Ray absorptiometry (DEXA), quantitative computed tomography (QCT), ultrasound densitometry, single energy x-ray absorptiometry (SEXA), quantitative ultrasound (QUS), radiographic absorptiometry or photodensitometry, single-photon absorptiometry (SPA), and dual-photon absorptiometry (DPA).
Note that the above list may not be comprehensive as the technology is constantly changing. SPA and DPA are now rarely used and may be considered obsolete. The following technologies are most commonly used:
A. Dual Energy X-Ray Absorptiometry (DEXA)
DEXA measures bone mineral content and bone mineral density. It is a two-dimensional projection system in which an X-ray tube source, rather than a radioisotope, is used as a photon source, providing for more accurate and precise readings. DEXA is used to measure bone mineral in both the peripheral appendicular skeleton and in axial skeletal sites, e.g., wrists, hip, spine, or total skeleton.
B. Quantitative Computed Tomography (QCT)
QCT depends on the differential absorption of ionizing radiation by calcified tissue and is used for central measurements only. Compared to DEXA, QCT is less readily available and associated with relatively high radiation exposure and relatively high costs.
C. Ultrasound Densitometry
Ultrasound densitometry is a technique for measuring BMD at peripheral sites, typically the heel, but also the tibia and phalanges. Compared to osteoporotic bone, normal bone demonstrates higher attenuation of the ultrasound wave, and is associated with a greater velocity of the wave passing through bone. Ultrasound densitometry has no radiation exposure, and machines may be purchased for use in an office setting.
Bone density measurements are covered once per lifetime for general screening for osteoporosis for women beginning at age 65 as part of the Healthy You! Wellness benefit. Measurements for screening are limited to the hips or spine using the DEXA technique.
The decision to perform bone density assessment should be based on an individual's fracture risk profile and skeletal health assessment. Bone mineral density (BMD) measurement is not indicated unless the results will influence treatment decisions.
Initial, Repeat and Serial BMD
A. An initial measurement of BMD at the hip or spine may be considered medically necessary to assess fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis. Therefore, BMD testing may be considered medically necessary for the following conditions:
*Risk factors included in the WHO Fracture Risk Assessment Model (FRAX) are:
B. Repeat measurements for individuals with risk factors who previously tested normal may be considered medically necessary at an interval not more than every 5 years.
C. Serial measurements to monitor treatment response for individuals with risk factors may be considered medically necessary not more frequent than every 3 years when the information will affect treatment decisions such as duration of therapy.
D. Serial measurements to monitor bone density for individuals on aromatase inhibitors may be considered medically necessary not more frequent than every 2-3 years when the information will affect treatment decisions. Currently, three aromatase inhibitors are approved by the FDA: letrozole (Femara®), anastrazole (Arimidex®), and exemestane (Aromasin®).
POLICY EXCEPTIONSState Health Plan (State and School Employees): Bone density studies are covered for women once every 2 years beginning at age 60 under the Plan's wellness benefits.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Services performed outside the clinical indications contained in the Medical Policy will be considered not medically necessary.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY4/1993: Approved by Medical Policy Advisory Committee (MPAC)
2/1997: Expanded clinical indications approved by MPAC. Limited to DEXA method only, once every 12 months.
6/1999: Interim policy revision: Included use of quantitative ultrasound (QUS) as an approved method
8/1999: Addition of QUS approved by MPAC
11/2000: Reviewed by MPAC; no changes
5/21/2001: Code Reference section revised; non-covered codes table added
10/15/2001: Verbiage revised under "policy" section; "Reimbursement is not provided for SPA, DPA or QCT bone densitometry techniques" to "SPA, DPA and QCT bone densitometry techniques are considered investigational and not eligible for coverage."
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007.
12/22/2009: Title revised to include “Mineral.” Description Section updated to add Quantitative Computed Tomography (QCT) and Ultrasound Densitometry, removed Quantitative Ultrasound. Policy Statement Section totally revised to include: screening for osteoporosis covered once for women at age 50 as part of Healthy You! Wellness benefit, changed criteria of when initial measurements may be considered medically necessary, added World Health Organization (WHO) Risk Assessment Model; changed criteria for repeat measurements with specific interval guidelines; added criteria for serial measurements to monitor treatment response with specific interval guidelines.Code reference section updated. CPT codes 76499, 77078, 77079 and 77082 were added to covered table. CPT Codes 77083, 78350 and 78351 were moved from non-covered to covered table. Removed deleted code Q9952 from the covered table. ICD-9 diagnosis code range 250.01-250.93, 252.00, 252.02, 252.08, 253.1, 263.8, 263.9, 307.1, 307.51, 493.81, 493.82, 571.0-571.9 code range, 714.1-714.9 code range, 733.10-733.19 code range, V82.81 and V85.0 added to covered table. ICD-9 diagnosis codes V86.0 and V86.1 deleted from covered table. Non-covered table deleted.
09/07/2010: Added policy statement regarding aromatase inhibitors to indicate that serial measurements to monitor bone density for individuals on aromatase inhibitors may be considered medically necessary not more frequent than every 2-3 years when the information will affect treatment decisions.
11/08/2010: Added ICD-9 code V07.52 to the Covered Codes table.
09/14/2011: Added the following verbiage to the Policy Exceptions section: State Health Plan (State and School Employees): Bone density studies are covered for women once every 2 years beginning at age 60 under the Plan's wellness benefits.
03/27/2012: Policy reviewed; no changes.
07/19/2013: Policy reviewed; no changes.
07/11/2014: Policy reviewed; no changes.
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77085 and 77086.
07/10/2015: Policy reviewed; no changes.
08/26/2015: Medical policy revised to add ICD-10 codes. Removed deleted CPT code 77079 and ICD-9 procedure code 88.98 from the Code Reference section.
01/01/2016: Policy statement updated to change the once per lifetime general osteoporosis screening for women from age 50 to 65 under the Healthy You! Wellness benefit. Removed deleted code CPT code 77082.
06/08/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
SOURCE(S)Bone Densitometry Medical Policy established by the Blue Cross Blue Shield Association and nationally affiliated plans.
TEC Evaluations 1987: p. 307; 1993: Tab 2
Hayes Medical Technology Directory
Medicare Program Memorandum Transmittal No. AB-98-32
U.S. Preventive Services Task Force Recommendations: Osteoporosis Screening
Task Force Urges Routine Osteoporsis Screening for Women 65 and Older to Identify Those at Risk for Fracture, Press Release Date: September 16, 2002 (added 3/2003)
Heidi D. Nelson, M.D., M.P.H., Mark Helfand, M.D., M.P.H., Steven H. Woolf, M.D., M.P.H., Janet D. Allan, P.H.D., R.N., Screening for Postmenopausal Osteoporosis
U.S. Preventive Services Task Force Recommendations: Screening for Osteoporosis in Postmenopausal Women
Blue Cross Blue Shield Association policy # 6.01.01
Aromatase inhibitors Prescribing Information
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.