Notification

Bone Mineral Density (BMD) Testing


Notification Issue Date: 08/21/2018

This version of the policy will become effective 11/19/2018. The Company’s coverage position for pulse echo ultrasound was added to the policy. The following CPT code has been added to this policy: 0508T.



Medical Policy Bulletin


Title:Bone Mineral Density (BMD) Testing

Policy #:09.00.04i

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Bone mineral density (BMD) testing is considered medically necessary and, therefore, covered when the individual meets one of the following criteria:
  • Females 65 years of age and older, regardless of personal or familial risk factors
  • Males 70 years of age and older, regardless of personal or familial risk factors
  • Postmenopausal females younger than 65 years of age with one of the following risk factors:
    • Caucasian or Asian (nonblack) race
    • Late menarche and early menopause
    • Discontinuing estrogen therapy
  • Postmenopausal females younger than 65 years of age and males 50-69 years of age who have at least one personal or familial risk factor that includes but is not limited to the following:
    • Low weight and/or body mass index (BMI) (body weight of less than 127 pounds or BMI of less than 21 kg per m2)
    • Family history of osteoporosis or fracture in a first-degree relative
    • Personal history of prior low-trauma or vertebral fracture
    • Increased likelihood of falls
    • Current cigarette smoking
    • Low levels of physical activity
    • Excessive alcohol intake
    • Poor nutrition with low calcium or vitamin D intake
    • Hemochromatosis
    • Hypophosphatasia
    • Thalassemia
    • Multiple myeloma
    • Taking medications that cause hypogonadism
    • Thyrotoxicosis
    • Homocystinuria
    • 10-year major osteoporosis-related fracture probability ≥ 9.3% based on the US-adapted WHO absolute fracture risk model
    • Loss of height (e.g., thoracic kyphosis)
  • Females going through menopause if there is a risk factor associated with increased fracture risk such as low body weight, prior low-trauma fracture, or high-risk medication
  • Females with exercise-induced amenorrhea or oligomenorrhea
  • Individuals of any age with any of the following risk factors:
    • Personal history of bariatric surgery
    • A condition strongly associated with osteoporosis, including, but not limited to the following:
      • Primary hyperparathyroidism
      • Type 1 insulin-dependent diabetes
      • Untreated long-standing hyperthyroidism, hypogonadism, or premature menopause (younger than 45 years), chronic malnutrition or malabsorption, and chronic liver disease
      • Cystic fibrosis
      • Osteogenesis imperfecta
      • Rheumatoid arthritis
    • Currently taking or anticipate taking a medication associated with the development of low bone mass or bone loss (e.g., glucocorticoid, equivalent to prednisone, at least 5 mg per day, or greater, for more than three months) or with a condition associated with the development of low bone mass or bone loss (e.g., anorexia nervosa). Note: In addition to glucocorticoids, medications associated with low bone mass or bone loss include some anti-seizure medications and aromatase inhibitors (e.g., anastrazole).
    • Vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture
  • Individuals who have a low-trauma or no-trauma fracture after 50 years of age
  • Any individual being treated for osteoporosis, to monitor treatment effect

PERIPHERAL MEASUREMENT BMD TESTING
Peripheral measurement of BMD testing is considered medically necessary and, therefore, covered for one of the following indications: (BCBSA)
  • The hip/spine or hip/hip BMD cannot be performed (e.g., the individual is over the table limit for weight)
  • The individual has been diagnosed with hyperparathyroidism, when a BMD of the forearm is essential for diagnosis

FOLLOW-UP BMD TESTING
Follow-up BMD tests are considered not medically necessary and, therefore, not covered more than once every two years except when the results will impact the treatment decision for the individual. Follow-up BMD testing may be indicated in circumstances that include, but are not limited to, the following: (NAMS)
  • Monitoring individuals on long-term glucocorticoid therapy (e.g., taking at least 5 mg/day for at least three months)
  • Confirming baseline bone mass measurements to permit monitoring of individuals in the future only when a dual-energy X-ray absorptiometry (DXA/DEXA) system (axial skeleton) was not used for the initial measurement

The necessity of follow-up BMD testing at intervals of less than one year cannot be relied upon for treatment decisions when considering that the margin of error of the test is typically greater than the interval treatment effect on BMD. Test to test variability, even with the use of the same testing device, should be taken into account when addressing the expected effects of treatment.

NOT MEDICALLY NECESSARY

Single photon absorptiometry (Current Procedural Terminology [CPT] code 78350) and dual photon absorptiometry (CPT code 78351) are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

Performing both a peripheral and an axial BMD test on the same day is considered not medically necessary and, therefore, not covered.

EXPERIMENTAL/INVESTIGATIONAL
Pulse-echo ultrasound bone density measurement is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agency, other health care professionals, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation must be made available to the Company upon request.
Guidelines

Based on individual product requirements, member co-payments and limitations may vary for bone mineral density (BMD) testing.

In geographic areas with a capitated radiology program, BMD testing is included in the capitated radiology program. For preferred provider organization (PPO) members who use in-network providers, BMD testing is eligible for reimbursement when performed by a contracted diagnostic radiology provider and by certain participating specialists as defined under the radiology network rules.

FRACTURE PROBABILITY

The US-adapted World Health Organization (WHO) 10-year probability of a hip fracture and the 10-year fracture probability of any major osteoporosis-related fracture can be assessed using the Fracture Risk Assessment Tool (FRAX). This tool uses clinical risk factors with or without femoral neck bone density to calculate the 10-year probability of a major osteoporotic fracture (in the proximal part of the humerus, wrist, or hip or a clinical vertebral fracture) and a hip fracture calibrate to the fracture and death hazards. FRAX is not used for individuals 40 to 90 years of age who have already received pharmacologic treatment for osteoporosis.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, BMD testing is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for BMD testing.

Description

Bone strength, an aggregate of bone density and bone quality, is an important factor in bone health and resistance to fracture. Bone density is defined as the amount of mineral in a specific area, while bone quality refers to architecture, turnover, and mineralization. Low bone density and deterioration of bone tissue result in osteoporosis, a disease marked by an increase in bone fragility and susceptibility to fracture. Chronic diseases, surgical procedures to reduce caloric intake (e.g., bariatric surgery), or medical conditions such as anorexia nervosa and long-term glucocorticoid therapy can contribute to bone loss and are associated with secondary osteoporosis. Osteoporosis is an extremely common disease in the elderly due to age-related bone loss in both sexes and menopause-related bone loss in women. The World Health Organization (WHO) defines osteoporosis based on a bone mineral density that is 2.5 standard deviations or more below that found in healthy, young individuals.

The WHO Bone mineral density (BMD) measurement is the standard used for diagnosing osteoporosis. Bone density studies are used to identify individuals with osteoporosis and also may be used to monitor response to osteoporosis treatment. The tests are noninvasive, and their accuracy for predicting the risk of fracture has been compared with the use of cholesterol testing to predict heart disease and hypertension for stroke. BMD is measured in the central (hip and lumbar spine) or peripheral (forearm, wrist, finger, or heel) skeleton. Because most fractures occur in the hip and spine, measurements of the central skeleton are most predictive of fracture risk at these sites. The following are established methods for BMD testing:
  • Dual-energy X-ray absorptiometry (DXA, DEXA)
  • Single-energy X-ray absorptiometry (SEXA)
  • Radiographic absorptiometry (RA)
  • Quantitative computed tomography (QCT)
  • Ultrasound BMD studies (i.e., bone sonometry)

Dual-energy X-ray absorptiometry (DXA, DEXA) is the most widely used central densitometry and is considered to be the gold standard. Scan time is short, and radiation exposure is very low. Measurement of density at the proximal femur is used to predict fractures, while measurement of the lumbar spine is used to monitor response to treatment. Quantitative computed tomography (QCT) (also a central measurement), which is a three-dimensional BMD test, is calculated using the differential absorption of ionizing radiation by calcified tissue. Standard CT scanners can be used. QCT is the only technique that can distinguish between cortical and cancellous bone. QCT is expensive, is not widely available, and has relatively high radiation exposure.

Examples of peripheral measurements include peripheral DXA (pDXA), which measures BMD at the forearm, wrist, heel, or finger; or peripheral QCT (pQCT), which measures the wrist. Radiographic absorptiometry (RA) measures BMD at the metacarpals and phalanges. Radiographic quantitative ultrasound (QUS) measures BMD at the heel utilizing sound waves. SEXA measures BMD at the forearm. SEXA is not widely used in current practice.

Two additional methods to measure BMD are single photon absorptiometry and dual photon absorptiometry. Single photon absorptiometry provides a quantitative measurement of bone mineral and trabecular bone. Dual photon absorptiometry measures the absorption of a dichromatic beam by bone material. In current practice, these methods are rarely used. In particular, dual photon absorptiometry may be considered obsolete.

Pulse echo ultrasound is an additional method to estimate the density index. The density index is an estimate of pelvic bone mineral density. Pulse echo ultrasound measures the cortical thickness at the upper shaft of the tibia. The measurement and other clinical risk factors or individual characteristics are used to calculate the density index. Clinical studies have shown that pulse echo ultrasound may be useful at identifying individuals at increased risk for osteoporosis, but additional studies are needed to confirm the accuracy of predicting subsequent clinical fractures.

Various clinical and interest groups, including the National Osteoporosis Foundation (NOF), the US Preventive Services Task Force (USPSTF), the Centers for Medicare & Medicaid Services (CMS), and the International Society for Clinical Densitometry (ISCD) have published clinical guidelines for BMD testing. However, at this time, no definitive consensus has emerged. The USPSTF recommends initial BMD screening for all women over the age of 65 and postmenopausal females under the age of 65 at increased risk of osteoporosis. The NOF recommends screening for postmenopausal females who are younger than 65 years of age and have one additional risk factor. The NOF agrees with the USPSTF recommendation that females 65 years of age and older should be screened and adds the recommendation that males 70 years of age and older be tested regardless of risk factors. The NOF further provides indications for bone mineral testing for males between the ages of 50 and 69 years of age.
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Rosen CJ. Clinical practice. Postmenopausal osteoporosis. N Engl J Med. 2005; 353(6):595-603.

Rosen DS, American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010; 26(6):1240-1253.

Ross PD. Risk factors for osteoporotic fracture. Endocrinol Metab Clin North Am. 1998; 27(2):289-301.

Ross RW, Small EJ. Osteoporosis in men treated with androgen deprivation therapy for prostate cancer. J Urol. 2002; 167(5):1952-1956.

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Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY


76977, 77078, 77080, 77081


NOT MEDICALLY NECESSARY

78350, 78351


EXPERIMENTAL/INVESTIGATIONAL

0508T



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 09.00.04i
11/19/2018This version of the policy will become effective 11/19/2018. The Company’s coverage position for pulse echo ultrasound was added to the policy. The following CPT code has been added to this policy: 0508T.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 11/19/2018
Version Issued Date: 11/19/2018
Version Reissued Date: N/A

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