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:
- Is performed to identify bone mass, detect bone loss, or determine bone quality;
- Is performed with a bone densitometer (other than single-photon or dual-photon absorptiometry (DPA)) or a bone sonometer (i.e., ultrasound) device approved or cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR Part 807, or approved for marketing under 21 CFR Part 814;
- Includes a physician's interpretation of the results of the procedure.”
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:
- It is ordered by the physician or qualified nonphysician practitioner who is treating the patient following an evaluation of the need for a BMM and determination of the appropriate BMM to be used. A physician or qualified nonphysician practitioner treating the patient is one who furnishes a consultation or treats a patient for a specific medical problem, and who uses the results in the management of the patient. For the purposes of the BMM benefit, qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives.
- It is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b).
- It is reasonable and necessary for diagnosing and treating the condition of a patient who meets the eligibility criteria.
- In the case of an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, is performed with a dual-energy x-ray absorptiometry (DXA) system.
- In the case of any individual who meets the conditions described and who has a confirmatory BMM, is performed by a DXA system if the initial BMM was not performed by a DXA system. A confirmatory baseline BMM is not covered if the initial BMM was performed by a DXA system.
In order for the BMM to be covered, a patient must meet at least one of the conditions listed below:
- Men 70 years of age and older at risk for osteoporosis;
- Women 65 years of age and older at risk for osteoporosis;
- A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings. Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.
- An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
- An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.
- An individual with primary hyperparathyroidism.
- An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.
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:
- Monitoring patients on long-term glucocorticoid (steroid) therapy of more than 3 months.
- Confirming baseline BMMs to permit monitoring of patients in the future.
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.
- Single photon absorptiometry (procedure code 78350);
- Dual photon absorptiometry (procedure code 78351).
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.
04/2011, Coverage guidelines for bone mass measurements explained
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.
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.
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:
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.