Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA)

Policy #:09.00.40d

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.

Dual-energy x-ray absorptiometry (DEXA/DXA) used to screen for the presence of vertebral fractures is considered experimental/investigational because the safety and/or effectiveness of this service cannot be established by review of the available published literature.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, screening for vertebral fracture with dual-energy x-ray absorptiometry is not eligible for payment under the medical benefits of the Company’s products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The IVA (MXA-II) software option for the Hologic X-ray Bone Densitometer (Hologic, Inc.; Bedford, MA) received approval from the US Food and Drug Administration (FDA) under the 510(k) process on April 24, 2006.

The GE Dual-Energy Vertebral Assessment View software option (General Electric Healthcare Technologies; Waukesha, WI) received FDA approval under the 510(k) process on December 20, 2002.

Description

Vertebral fractures are highly prevalent in the elderly population, and epidemiologic studies have reported that these fractures are associated with an increased risk of future fractures regardless of normal bone mineral density findings. Currently, most vertebral fractures are found incidentally during lateral spine radiographs (x-rays). However, due to the high level of radiation exposure and cost, lateral spine radiographs are not recommended as a component of risk assessment for osteoporosis.

Recently, screening for the presence of vertebral fractures using dual-energy x-ray absorptiometry (DEXA/DXA) has been evaluated as a risk assessment tool for osteoporotic fracture. Manufacturers of DEXA/DXA technology have developed software that is used in conjunction with a bone densitometer to screen for vertebral fractures at the same time an individual is undergoing a bone mineral density evaluation. This imaging may also be referred to as morphometric x-ray absorptiometry (MXA), instant vertebral assessment (IVA), or lateral vertebral assessment (LVA). Although DEXA/DXA requires less exposure to radiation than traditional lateral spine x-rays, the overall resolution of DEXA/DXA images is inferior to those obtained on x-ray. In addition, the interference of the overlying ribs prohibits up to 10 percent of the vertebrae from being well visualized and appropriately evaluated.

Individuals who are diagnosed with low bone mass on bone mineral density testing may be candidates for pharmacologic treatment for decreased bone mass, regardless of the presence of vertebral fractures. It is, therefore, only individuals who have both non-osteoporotic bone mass and vertebral fractures who would be impacted by this screening. However, there is a lack of direct evidence to substantiate that individuals with both vertebral fractures and non-osteoporotic bone mineral density levels benefit from pharmacologic treatment for osteoporotic fracture prevention. No studies have enrolled individuals with both vertebral fractures and normal levels of bone mineral density, and studies that have enrolled individuals with both vertebral fractures and non-osteoporotic bone mineral density levels have not analyzed this subgroup separately.

The current published literature does not permit conclusions that screening for vertebral fractures using DEXA/DXA improves net health outcomes over the current practice of assessing osteoporosis risk using bone mineral density measurement alone.
References


Bhoopalam N, Campbell SC, Moritz T et al. Intravenous zoledronic acid to prevent osteoporosis in a veteran population with multiple risk factors for bone loss on androgen deprivation therapy. J Urol. 2009; 182(5):2257-64.

Binkley N, Krueger D, Gangnon R et al. Lateral vertebral assessment: a valuable technique to detect clinically significant vertebral fractures. Osteoporos Int. 2005; 16(12):1513-8.

Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center. Screening for vertebral fracture with dual x-ray absorptiometry [technology assessment]. Assessment Program Volume 20, No. 14. February 2006. [BCBSA Web site].

Cosman F, de Beur SJ, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25(8). Available at: https://cdn.nof.org/wp-content/uploads/2016/01/995.pdf. Accessed at January 10, 2018.

Cummings SR, Black DM, Thompson DE et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA. 1998; 280(24):2077-82.

Diacinti D, Del Fiacco R, Pisani D et al. Diagnostic Performance of Vertebral Fracture Assessment by the Lunar iDXA Scanner Compared to Conventional Radiography. Calcif Tissue Int. 2012; 91(5):335-42.

Diacinti D, Guglielmi G, Pisani D et al. Vertebral morphometry by dual-energy X-ray absorptiometry (DXA) for osteoporotic vertebral fractures assessment (VFA). Radiol Med. 2012; 117(8):1374-85.

Domiciano DS, Figueiredo CP, Lopes JB et al. Vertebral fracture assessment by dual X-ray absorptiometry: a valid tool to detect vertebral fractures in community-dwelling older adults in a population-based survey. Arthritis Care Res. 2013; 65(5):809-15.

Endocrine Society Osteoporosis in Men. 2012. Available online at:https://watermark.silverchair.com/jcem1802.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAacwggGjBgkqhkiG9w0BBwagggGUMIIBkAIBADCCAYkGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMRwt_GIEeY_efzvbfAgEQgIIBWqOGitDcuk-7qJaAl0AMs7i_VR6-8brr7AR_VRS7TROQl6fysL-trpfxrFL6R7cnlkSEjCVFIaA5Z05B9DweCWj8ol0xwd_11ViMNcybC7zU19TDXBBJsJgkzKua4Z5f8kqIF3FYlIyIoxZfjlE_VC_Z7T4hzuJY70eeQD25tgvcriHs-bs9-w44oWNdKLfxnlLwqmtPIa9hnkok3lIubdkNEg2XAar8iXzkpkU45eQzLQFidNVy4RwtGmbJ1LYBxz4A3FzaRAlsYvV2W6CQte2q_0WgJMiCgWw5p2o6ScYws2Xiu-KJZHHy_PnEvo7lFz-E2bON1MbNFWlhSwelDzoJti8ZOh9a2Pv3KVSJ9dghnMct-XoaRe2E7tQaropKVbxjowhDzqQfMGrDYYq7ijOLJpeJ_icLgN6yJ6Tyce9GmxEYbptcFJx7GbNehvJjNFNtmAJuEwVN2wQ. Accessed January 10, 2018.

Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. JAMA. 1999;282(7):637-45.

Ferrar L, Jiang G, Barrington NA, Eastell R. Identification of vertebral deformities in women: Comparison of radiological assessment and quantitative morphometry using morphometric radiography and morphometric X-ray absorptiometry. J Bone Miner Res. 2000;15(3):575-85.

Ferrar L, Jiang G, Clowes J et al. Comparison of densitometric and radiographic vertebral fracture assessment using the algorithm-based qualitative (ABQ) method in postmenopausal women at low and high risk of fracture. J Bone Miner Res. 2007; 23(1):103-11.

Ferrar L, Jiang G, Eastell R, Peel NF. Visual identification of vertebral fractures in osteoporosis using morphometric X-ray absorptiometry. J Bone Miner Res. 2003;18(5):933-8.

Greenspan SL, Nelson JB, Trump DL et al. Effect of once-weekly oral alendronate on bone loss in men receiving androgen deprivation therapy for prostate cancer. Ann Intern Med. 2007; 146(6):416-24.

Greenspan SL, von Stetten E, Emond SK, et al. Instant vertebral assessment: a noninvasive dual X-ray absorptiometry technique to avoid misclassification and clinical mismanagement of osteoporosis. J Clin Densitom. 2001;4(4):373-380.

Harris ST, Watts NB, Genant HK, et al. Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group. JAMA. 1999;282(14):1344-52.

Jager PL, Jonkman S, Koolhaas W et al. Combined vertebral fracture assessment and bone mineral density measurement: a new standard in the diagnosis of osteoporosis in academic populations. Osteoporos Int. 2011; 22(4):1059-68.

Kanis JA, Barton IP, Johnell O. Risedronate decreases fracture risk in patients selected solely on the basis of prior vertebral fracture. Osteoporos Int. 2005; 16(5):475-82.

Kanterewicz E, Puigoriol E, Garcia-Barrionuevo J et al. Prevalence of vertebral fractures and minor vertebral deformities evaluated by DXA-assisted vertebral fracture assessment (VFA) in a population-based study of postmenopausal women: the FRODOS study. Osteoporos Int. 2014; 25(5):1455-64.

Liberman UA, Weiss SR, Broll J, et al. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. N Engl J Med. 1995;333(22):1437-1443.

Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Available online at: http://www.menopause.org/docs/default-document-library/psosteo10.pdf?sfvrsn=2
Accessed January 10, 2018.

Mrgan M, Mohammed A, Gram J. Combined Vertebral Assessment and Bone Densitometry Increases the Prevalence and Severity of Osteoporosis in Patients Referred to DXA Scanning. J Clin Densitom. 2013; 16(4):549-53.

National Osteoporosis Foundation (NOF). Physician's Guide to Prevention and Treatment of Osteoporosis; 2003 updated in2009.

Quandt SA, Thompson DE, Schneider DL et al. Effect of alendronate on vertebral fracture risk in women with bone mineral density T scores of -1.6 to -2.5 at the femoral neck: the Fracture Intervention Trial. Mayo Clin Proc. 2005; 80(3):343-9.

Rea JA, Li J, Blake GM, et al. Visual assessment of vertebral deformity by X-ray absorptiometry: a highly predictive method to exclude vertebral deformity. Osteoporos Int. 2000;11(8):660-8.

Rea JA, Chen MB, Li J, et al. Morphometric X-ray absorptiometry and morphometric radiography of the spine: a comparison of prevalent vertebral deformity identification. J Bone Miner Res. 2000;15(3):564-74.

Rosen HN, Vokes TJ, Malabanan AO et al. The official positions of the International Society for Clinical Densitometry: vertebral fracture assessment. J Clin Densitom. 2013; 16(4):482-8.

Schousboe JT, DeBold CR, Bowles C, et al. Prevalence of vertebral compression fracture deformity by X-ray absorptiometry of lateral thoracic and lumbar spines in a population referred for bone densitometry. J Clin Densitom. 2002;5(3):239-46.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. GE Dual-Energy Vertebral Assessment View Software Option [510(k) market approval]. [FDA Web site]. 12/20/2002. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf2/K023554.pdf. Accessed January 10, 2018.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. IVA (MXA-II) software option for the X-Ray bone densitometers [510(k) market approval]. [FDA Web site]. 04/24/2006. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf6/K060111.pdf. Accessed January 10, 2018.

US Preventive Services Task Force. Osteoporosis: Screening. January 2011. Available online at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm. Accessed January 10, 2018.

Vestergaard P. Anti-resorptive therapy for the prevention of postmenopausal osteoporosis: When should treatment begin? Treat Endocrinol. 2005;4(5):263-77.

Vokes TJ, Dixon LB, Favus MJ. Clinical utility of dual-energy vertebral assessment (DVA). Osteoporos Int. 2003;14(11):871-8.





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)

77085, 77086


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)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 09.00.40d:
01/31/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA).

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

Version Effective Date: 02/18/2016
Version Issued Date: 02/18/2016
Version Reissued Date: 01/31/2018

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.