Frequency Guidelines
Coverage for eligible bone density studies is limited to one test every 365 days from the date of the previous bone density study, regardless of the anatomic area tested or imaging modality used to perform the study. However, more frequent bone mass measurements are considered medically necessary under the following circumstances:

• To allow simultaneous axial (spine, hips, pelvis) and peripheral (forearm, radius, wrist) bone density testing for hyperparathyroidism (252.00, 252.01, 252.02, 252.08);
• To allow peripheral (forearm, radius, wrist) bone density testing in lieu of the axial skeleton (spine, hips, pelvis) in the very obese patient [defined as a patient with a BMI of 35 or greater (V85.35-V85.39, V85.4)] when the patient’s weight exceeds the weight limit for the DXA table;
• To allow peripheral (forearm, radius, wrist) bone density testing when the hips or spine cannot be measured or interpreted because of severe arthritis and/or previous surgery.

When a bone density study is reported with a diagnosis code that is covered under the "general coverage" criteria, but  the service falls within the 365 day frequency limitation and the diagnosis or condition is not one that meets the expanded criteria described above, it will be denied as not medically necessary. 

Routine Bone Density Studies
Routine bone density studies performed as a screening test for osteoporosis are eligible for members with coverage for Preventive Health services according to the preventive scheduled published annually. (Refer to the member's individual benefits for coverage information on this service.) Routine conditions for this test include, but are not limited to, age-related menopause and surgically-induced menopause (e.g., following oophorectomy).

General Coverage Guidelines
Bone density studies are most commonly used in the evaluation of osteoporosis, sometimes referred to as osteopenia. This condition might be the result of circumstances such as alcoholism, hyperparathyroidism, malabsorption, chronic renal disease, Cushing's syndrome. This list is not all inclusive. Bone density studies (codes 77080, 77081, 77078, 77079, 78351) are eligible for the following indications:

• The patient is on long term steroid therapy (3 month duration or longer with a dosage of 5 mg per day of prednisone, or equivalent)(V58.65);
• The patient is on long term phenytoin (e.g., Dilantin) therapy (3 month duration or longer). It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation;
• To determine if significant osteoporosis is present when associated with vertebral abnormalities on x-ray (such as compression fractures) or radiographic evidence of osteopenia (733.90);
• Fractures of the hip, wrist, or spine in the absence of appropriate severe trauma (733.12, 733.13, 733.14);
• Documented loss of height of 1.5 inches or greater. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation;
• To monitor and evaluate response to ongoing restorative treatment (e.g., Fosamax) for patients with documented osteoporosis (733.00, 733.01, 733.02, 733.03, 733.09);
• The patient suffers from one of the following calcium-wasting endocrinopathies:
  
  • Cushing's Syndrome (255.0)
  • Hyperparathyroidism (252.00, 252.01, 252.02, 252.08)
  • Hyperthyroidism (242.00-242.91)
  • Hypogonadism (256.39, 257.1, 257.2)(except for uncomplicated, naturally occurring, or surgically induced post-menopausal clinical cases)
  • Prolactinoma (194.3, 227.3, 237.0, 239.7)
  • Celiac Sprue (579.0)
• The patient has prostate cancer with androgen deprivation. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation;
• Post ablative ovarian failure (256.2);
• Breast cancer patients who are on aromatase inhibitors (V07.52). It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.
• Symptomatic menopausal or female climacteric states (627.2). This diagnosis is only eligible once every two years.

Single Energy X-ray Absorptiometry (SEXA)(code G0130) and bone sonometry (code 76977) are methods that are considered screening in nature.

Single Photon Absorptiometry (SPA)(code 78350) and radiographic absorptiometry (e.g., photodensitometry, radiogrammetry)(code 77083) are methods that are not generally accepted by the medical community as clinically useful in diagnosing or treatment. As such, they are considered not medically necessary and are not eligible for payment.

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A participating, preferred or network 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 should be maintained in the provider's records.

For information on zoledronic acid (Reclast®, Zometa®), refer to Medical Policy Bulletin I-42.

For information on ibandronate sodium (Boniva®), refer to Medical Policy Bulletin I-95.

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.

FEP covers bone density tests, both screening and diagnostic.

The Challenges of Peripheral Bone Density Testing - Which Patients Need Additional Central Density Skeletal Measurements?, Journal of Clinical Densitometry, Vol. 1, No. 3, Fall 1998

Stiffness in Discrimination of Patients with Vertebral Fractures, Osteoporosis International, Vol. 9, 1999

The American Association of Clinical Endocrinologists and The American Association of Endocrine Surgeons Position Statement on the Diagnosis and Management of Primary Hyperparathyroidism, 2005

National Blue Cross Blue Shield MPRM 6.01.01

ACR Appropriateness Criteria, 2007

The International Society for Clinical Densitometry (ISCD), Dual-Energy X-Ray Absorptiometry Technical Issues:  The 2007 ISCD Official Positions.

The National Osteoporosis Foundation Clinician’s Guide to Prevention and Treatment of Osteoporosis, 2008.

American College of Radiology (ACR) Practice Guidelines for the Performance of Dual-Energy X-Ray  Absorptiometry, 2008.