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DESCRIPTIONVertebral fractures are highly prevalent in the elderly population, and epidemiologic studies have found that these fractures are associated with an increased risk of future spine or hip fractures independent of bone mineral density. Only 20%–30% of vertebral fractures are recognized clinically; the rest are discovered incidentally on lateral spine radiographs. Lateral spine x-rays have not been recommended as a component of risk assessment for osteoporosis, because of the cost, radiation exposure, and the fact that the x-ray would require a separate procedure in addition to the bone mineral density study. However, lateral spine images can be obtained using bone densitometers, and thus it is possible to screen for vertebral fractures at the same time a subject is undergoing assessment of bone mineral density. Vertebral fracture assessment (VFA) differs from radiological detection of fractures, as VFA uses a lower radiation exposure and can detect only fractures, while traditional x-ray images can detect other bone and soft tissue abnormalities in addition to spinal fractures. VFA may be referred to as dual x-ray absorptiometry (DEXA or DXA) or morphometric x-ray absorptiometry (MXA). Manufacturers have also referred to this procedure as “Instant Vertebral Assessment,” (IVA) or Radiographic Vertebral Assessment (RVA) (Hologic), or Dual Energy Vertebral Assessment (DVATM ) previously known as “Lateral Vertebral AssessmentTM” (LVA) (GE Lunar Medical Systems).
For both lateral spine x-rays and images with densitometry, vertebral fractures are assessed visually. While a number of grading systems have been proposed, the semiquantitative system of Genant is commonly used. This system grades the deformities from I to III, with grade I representing a 20%–24% reduction in vertebral height and ranging up to grade III, which is a 40% reduction in height. The location of the deformity within the vertebrae may also be noted. For example, if only the mid-height of the vertebrae is affected, the deformity is defined as an endplate deformity; if both the anterior and mid-heights are deformed, it is a wedge deformity; and if the entire vertebrae is deformed, it is classed as a crush deformity. A vertebral deformity of at least 20% loss in height is typically considered a fracture. Accurate interpretation of both lateral spine x-rays and VFA imaging is dependent on radiological training. Thus, device location and availability of appropriately trained personnel may influence diagnostic accuracy.
Many densitometers have received 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA) such as Hologic’s IVA and GE’s DVATM noted here. To perform vertebral fracture assessment with a densitometer, additional software is needed and it must have 510(k) marketing clearance from the FDA as well.
See separate medical policy for Bone Mineral Density Studies.
POLICYScreening for vertebral fractures using dual x-ray absorptiometry (DEXA of DXA) is considered investigational.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY3/31/2005: Approved by Medical Policy Advisory Committee (MPAC)
6/6/2005: Code Reference section completed
3/16/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
5/15/2007: Policy reviewed, description updated. Morphometric absorptiometry changed to dual x-ray absorptiometry in policy statement. Policy name changed to "Vertebral Fracture Assessment with Densitometry." Previously named "Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DEXA)."
04/19/2011: Policy description and statement unchanged. Added FEP verbiage to the Policy Exceptions section. Removed deleted CPT code 76077 from the Code Reference section.
03/02/2012: Policy reviewed; no changes.
04/03/2013: Policy reviewed; no changes.
SOURCE(S)Blue Cross Blue Shield Association Policy # 6.01.44
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.