Highmark Medicare Advantage Medical Policy in West Virginia

Section: CMS National Guidelines
Number: N-196
Topic: Bone Mass Measurements - NCD 150.3
Effective Date: August 8, 2011
Issued Date: August 8, 2011

General Policy

For services prior to August 8, 2011, see policy X-24.

A bone mass measurement (BMM) study is defined as a “radiologic or radioisotopic procedure or other procedure that meets all of the following conditions:

Indications and Limitations of Coverage

Coverage is provided for a BMM to monitor osteoporosis drug therapy, and as a preventive service for those patients meeting the criteria for a screening examination.

Medicare Advantage will cover a BMM when the following conditions are met:

In order for the BMM to be covered, a patient must meet at least one of the conditions listed below:

Frequency of Studies
Medicare Advantage pays for a screening BMM once every 2 years (at least 23 months have passed since the month the last covered BMM was performed).

When medically necessary, Medicare Advantage may pay for more frequent BMMs. Examples include, but are not limited to, the following medical circumstances:

Peripheral bone measurement scans are used primarily for screening purposes. Peripheral bone measurement scans are not FDA-approved for continued follow-up of chronic conditions or osteoporosis treatment. Therefore, peripheral studies (CPT/HCPCS codes 77078, 77079, 77081, 76977, G0130) would not be medically necessary more often than every two years.

Reasons for Noncoverage

The following methods for bone mass measurement are not covered under Medicare because they are not considered reasonable and necessary.

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

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.

Procedure Codes

769777707877079770807708177083
7835078351G0130   

Coding Guidelines

Publications

Provider News

04/2011, Coverage guidelines for bone mass measurements explained

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-03, Section 150.3

CMS Online Manual Pub. 100-02, Chapter 15, Section 80.5

CMS Online Manual Pub. 100-04, Chapter 13, Section 140.1

CMS Transmittal R69NCD, CR 5521

CMS Transmittal R70BP, CR 5521

CMS Transmittal R1236CP, CR 5521

CMS Transmittal R1416CP, CR 5847

Qaseem A, Snow A, Shekelle P, Hopkins, Jr R, Forciea MA, Owens DK. Screening for Osteoporosis in Men: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2008;148:680-684.

Liu H, Paige NM, Goldzweig CL, Wong E, Zhou A, Suttorp MJ, Munjas B, Orwoll E, Shekelle P. Screening for Osteoporosis in Men: A Systematic Review for an American College of Physicians Guideline. Ann Intern Med. 2008;148:685-701.

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Covered Diagnosis Codes

Patients who qualify by statute for osteoporosis screening may be evaluated by studies that are characterized by CPT codes 77078, 77079, 77080, 77081, 77083, 76977, and G0130. The following is a list of ICD-9-CM codes that support the medical necessity of osteoporosis screening.

241.0246.9252.00-252.08255.0
256.2256.31256.39259.3
627.2627.4733.00733.01
733.02733.03733.09733.11-733.16
733.19733.90733.93733.94
733.95733.96733.97733.98
781.91V49.81V58.65V82.81

Covered Diagnosis Codes under special circumstances (see policy for specifics)

Once the diagnosis of osteoporosis has been established, the effectiveness of treatment can ONLY be monitored using a DXA (CPT code 77080). The valid ICD-9-CM codes for the established diagnosis of osteoporosis are:

255.0733.00733.01733.02
733.03733.09733.90 

Covered Diagnosis Codes under special circumstances (see policy for specifics)

Peripheral scans are characterized by CPT codes 76977, 77078, 77079, 77081, 77083, G0130. These scans are NOT covered for the monitoring of the effectiveness of osteoporosis therapy. Therefore, if any of the following codes are the only codes submitted on the claim, the claim will be denied as not medically necessary.

255.0733.00733.01733.02
733.03733.09733.90 

Glossary





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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.