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Date Printed: December 18, 2017: 11:22 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-70000-21

Original Effective Date: 08/15/96

Reviewed: 02/23/17

Revised: 03/15/17

Subject: Bone Mineral Density Studies

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Bone mineral density (BMD) studies can be used to identify individuals with osteoporosis and as a tool to monitor response to osteoporosis treatment; the goal of BMD measurements is to reduce the risk of fracture. Osteoporosis is a condition characterized by low bone mass, deterioration of bone tissue and disruption of bone architecture, compromised bone strength and an increase in the risk of fracture. Osteoporosis is more common in women than men. In the World Health Organization (WHO) report (2004), osteoporosis is defined as a BMD 2.5 standard deviations (SD) or more below the average value for young healthy woman (T-score of <-2.5 SD). Identified risk factors for bone loss and osteoporosis include, but is not limited to: older age, female gender, menopause, family history of fracture; medications that may cause bone loss (e.g., steroids (cortisone, prednisone), anti-seizure, aromatase inhibitors, gonadotropin releasing hormone, proton pump inhibitors; and medical conditions (e.g., autoimmune disorder (rheumatoid arthritis, lupus), endocrine disorder (diabetes, hyperparathyroidism). Risk factors for fracture include, but are not limited to low bone mass, low bone strength, a personal history of fracture as an adult, and a history of fracture in a first-degree relative (NOF, 2011).

BMD can be measured with several bone mass measurement technologies in a variety of skeletal sites; central (e.g., hip, spine) or peripheral (e.g., wrist, finger, heel). While BMD measurements are predictive of fragility fractures at all sites, central measurements of the hip and spine are the most predictive. Fractures of the hip and spine (e.g., vertebral fractures) are also considered to be the most clinically relevant. The following bone mass technologies are most commonly used for BMD measurement:

Dual-Energy X-Ray Absorptiometry (DXA)

DXA is used to measure BMD at central sites (hip and spine). DXA can also be used to measure peripheral sites (forearm, wrist, and finger); DXA performed at peripheral sites is usually referred to as pDXA. DXA is the most commonly used technique to measure BMD because of its ease of use, low radiation exposure, and its ability to measure BMD at both the hip and spine. DXA can also be used to measure peripheral sites, such as the wrist and finger. DXA generates two x-ray beams of different energy levels to scan the region of interest and measure the difference in attenuation as the low- and high-energy beams pass through the bone and soft tissue. The low-energy beam is preferentially attenuated by bone, while the high-energy beam is attenuated by both bone and soft tissue. This differential attenuation between the two beams allows for correction for the irregular masses of soft tissue, which surround the spine and hip, and therefore the measurement of bone density at those sites.

Quantitative Computed Tomography (QCT)

QCT depends on the differential absorption of ionizing radiation by calcified tissue and is used for central measurements (spine, proximal femur, distal forearm and whole body). Compared to DXA, QCT is less readily available and associated with relatively high radiation exposure and relatively high cost.

Ultrasound Densitometry

Ultrasound densitometry is a technique for measuring BMD at peripheral sites, typically the heel but also the tibia and phalanges. Compared to osteoporotic bone, normal bone demonstrates higher attenuation of the ultrasound wave and is associated with a greater velocity of the wave passing through bone. Ultrasound densitometry has no radiation exposure, and machines may be purchased for use in an office setting.

The following bone mass technologies are less commonly used for BMD measurement:

The American Association of Clinical Endocrinologists (AACE) (2005) states that most patients with primary hyperparathyroidism (PHPT) should undergo bone density screening. PHPT is a disease characterized by hypercalcemia attributable to autonomous overproduction of parathyroid hormone. Losses of BMD from PHPT are more pronounced in the forearm (cortical bone) than in the spine (trabecular bone) and hip (mixed cortical and trabecular bone) but may occur at all skeletal sites. Although forearm losses of BMD may be more commonly associated with PHPT, the benefit from surgical treatment is more notable for the hip and spine because of the morbidity and mortality associated with fracture. Patients with PHPT should undergo DEXA scanning of these 3 sites for reliable documentation of their BMD satus as a criterion for recommending parathyroidectomy.

Fracture Risk Assessment Tool (FRAX®)

Many different risk assessment instruments have been developed to predict risk for either low bone BMD or fractures. The Fracture Risk Assessment tool (FRAX®), developed by the World Health Organization (WHO) and the National Osteoporosis Foundation (NOF), is one of the most widely used instruments to predict individual fracture risks. The FRAX® model have been developed from study population based cohorts from Europe, North America, Asia and Australia. The FRAX® tool is computer-driven and a paper-based version is available and can be downloaded for office use. The FRAX® algorithms calculate the 10 year probability of a hip fracture and the 10 year probability of a major osteoporotic fracture (spine, forearm, shoulder) (WHO, 2004).

Vertebral Fracture Assessment (VFA)

Several densitometers with specialized software are able to perform vertebral fracture assessment (VFA) in conjunction with DXA. VFA differs from radiologic detection of fractures, as VFA uses a lower radiation exposure and can detect only fractures, while traditional x-ray images can detect other bone and soft tissue abnormalities in addition to spinal fractures. Manufactures refer to this procedure as instant vertebral assessment (IVA), radiographic vertebral assessment (RVA), dual energy vertebral assessment (DVA), densitometric spine imaging or lateral vertebral assessment (LVA). Additional software is needed when VFA is performed with a densitometer. The NOF (2010) states VFA imaging of the thoracic and lumbar spine using central DXA scanners should be considered at the time of BMD assessment when the presence of a vertebral fracture not previously identified may influence clinical management of the patient.

Various devices for BMD (e.g., Hologic) and VFA (e.g., Lunar Dual Energy Vertebral Assessment, Hologic Instant Vertebral Assessment software) have received clearance for marketing by the U.S. Food and Drug Administration (FDA).

POSITION STATEMENT:

Central bone mineral density measurement with dual-energy absorptiometry (DXA) meets the definition of medical necessity for any of the following indications:

Peripheral bone mineral density measurement using the forearm (cortical bone), meets the definition of medically necessity when performed for asymptomatic primary hyperparathyroidism (PHPT) where consideration for surgery is determined by the bone density level.

Peripheral bone mineral density measurement performed on any body part other than the forearm (cortical bone) for asymptomatic primary hyperparathyroidism (PHPT) is considered experimental or investigational there is insufficient clinical evidence in the peer-reviewed medical literature to support the use of peripheral bone density measurement performed on any body part other than the forearm (cortical bone) for asymptomatic primary hyperparathyroidism (PHPT) where consideration for surgery is determined by the bone density level.

Screening for osteoporosis

NOTE: Refer to member’s contract benefits.

Central bone mineral density measurement with dual-energy absorptiometry (DXA) when used for screening for osteoporosis may be eligible for coverage for the following:

Screening for vertebral fractures using dual x-ray absorptiometry is considered experimental or investigational there is insufficient clinical evidence in the peer-reviewed medical literature to support the use of screening for vertebral fractures using dual x-ray absorptiometry.

Bone mineral density study performed for screening when a preventive health benefit/wellness benefit is not available is not eligible for coverage.

Bone mineral density study for all other indications not included above is considered not medically necessary.

BILLING/CODING INFORMATION:

The following codes may be used to describe bone mineral density measurement/study.

CPT Coding:

76977

Ultrasound bone density measurement and interpretation, peripheral site(s), any method

77078

Computed tomography bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)

77080

Dual energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)

77081

Dual energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

77085

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture

77086

Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

78350

Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry (SPA)

78351

Bone density (bone mineral content) study, one or more sites; single photon absorptiometry; dual photon absorptiometry, 1 or more sites

HCPCS Coding:

G0130

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

REIMBURSEMENT INFORMATION:

Bone mineral density measurement/study (76977, 77078, and G0130) are limited to one (1) of any type study in a twelve (12) month period.

Bone mineral density study (77080, 77081, 77085, 77086, 78350, and 78351) are limited to two (2) of any type study in a twelve (12) month period.

Repeat or serial bone mineral density (BMD) measurement/study is usually not indicated more frequently than once every 2 years. Repeat or serial BMD more frequent than every 2 years requires documentation that additional BMD measurements will alter treatment decision or clinical management (e.g., monitoring or evaluation of response to treatment, initiation or change in clinical management, initiation or change in pharmacologic treatment).

Documentation should include reason for repeat or serial BMD measurement/study, current BMD results, including, but not limited to study comparison to prior BMD study (assessment of whether any changes in measured BMD are statistically significant), a statement about fracture risk and BMD results: according to the World Health Organization (WHO): a T-score of -1.0 or above is normal bone density, a T-score between -1.0 and -2.5 is considered low bone density or osteopenia, BMD Z-score above -2.0 are normal, BMD Z-scores of -2.0 and lower are considered low bone density.

Re-imaging or additional imaging due to technically limited exam is the responsibility of the imaging provider.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for bone mineral density measurement/study.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology reason for study

18785-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study-date and time

18779-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study observation

18834-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-study observation

18782-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-impression

19005-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology study-recommendation (narrative)

18783-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Bone Mineral Density Studies, (L36356) located at fcso.com.

DEFINITIONS:

Bone densitometry: a diagnostic technique used to measure the amount of minerals in bone, and is designed to help predict who needs treatment to protect from bone loss, and predict who is at risk for fractures.

Dual-Energy X-ray Absorptiometry (DEXA): the gold standard for the diagnosis of osteoporosis; most widely used densitometry technology (measures multiple skeletal sites). DXA of the femoral neck is considered to be the best predictor of hip fracture and is comparable with DXA measurements of the forearm for predicting fractures at other skeletal sites. There are two types of DXA scans: peripheral DXA (pDXA): measures bone density in the forearm (lower arm), wrist finger or heel and central DXA: measures lumbar spine and hips (this scan is best scan to predict risk of fractures).

Dual-Photon Absorptiometry (DPA): measures bone mineral content at axial skeletal sites, e.g., spine and hip, using gadolinium-153 as the isotopic source of photons emitted at two energy levels. It is also use to measure total body calcium and provides a measurement of both cortical and trabecular bone mineral density.

Osteoporosis: reduction in bone mineral density (BMD) of 2.5 standard deviations (SD) or more below the mean of young healthy adults, leading to increased susceptibility to fractures.

Peripheral bone density testing: measures bone density in the forearm (lower arm), wrist, finger or heel. The types of peripheral test are: pDXA (peripheral dual energy x-ray absorptiometry), QUS (quantitative ultrasound) and pQCT (peripheral quantitative computed tomography).

Quantitative Computed Tomography (QCT): measures volumetric trabecular and cortical bone density and cortical bone density at the spine and hip, measured in milligram per cubic centimeter.

Radiographic Absorptiometry (RA): measures the small bones of the hand using computer-assisted x-ray densitometry. RA is also known as photodensitometry and radiographic densitometry. Lightly exposed x-rays are taken under different settings, and the computer scanner compares the density of bone to other tissue, and is compared to normal values based on age and sex.

Single Energy X-ray Absorptiometry (SEXA): measures bone mineral content of the arms and legs.

Single-Photon Absorptiometry (SPA): measures appendicular bone mass, e.g., wrist or calcaneous, using a monoenergetic photon source and a scintillation detector. SPA provides a measurement of mineral density of primary cortical and, to a lesser degree, trabecular bone.

Ultrasound densitometry:

RELATED GUIDELINES:

Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition and Other Body Composition Techniques, 04-70000-22

OTHER:

Coverage for screening bone density measurement is determined by the member’s/subscriber’s contract benefits. If the member/subscriber has a preventive health benefit/wellness benefit, screening bone mineral density study may be eligible for coverage.

Florida Statute 627.6691 Coverage for Osteoporosis Screening, Diagnosis, Treatment, and Management.

Any health insurance policy that covers a resident of this state and that is issued, amended, delivered, or renewed in this state after October 1, 1996, must provide coverage for the medically necessary diagnosis and treatment of osteoporosis for high-risk individuals, including, but not limited to, estrogen-deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long-term glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals who have a family history of osteoporosis.

Other names used to report bone mineral density studies:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Bone densitometry
Bone mass measurement
DEXA (dual-energy X-ray absorptiometry).

REFERENCES:

  1. ACOG Committee Opinion: Low Bone Mass (Osteopenia) and Fracture Risk, Number 407 May 2008. Retracted article 2012.
  2. American College of Radiology (ACR) Appropriateness Criteria® Osteoporosis and Bone Mineral Density, 2010.
  3. ACR–SPR–SSR Practice Parameter for the Performance of Dual-Energy X-ray Absorptiometry (DXA), Revised 2013.
  4. ACR Practice Guideline for the Performance of Quantitative Computed Tomography (QCT) Bone Densitometry, 2008.
  5. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Prevention and Treatment Postmenopausal Osteoporosis. Endocrine Practice 2010; 16(3): 1-37.
  6. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis. Endocrine Practice 2016; 22(4): 1-42.
  7. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause. Endocrine Practice 2011; 17(Suppl 6); 1-25.
  8. American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons Position Statement on the Diagnosis and Management of Primary Hyperparathyroidism. Endocrine Practice 2005; 11(1): 49-54.
  9. American College of Obstetricians and Gynecologists (ACOG) News Release-Recommendations for Bone Density Screening for Osteoporosis, 02/28/02.
  10. Blue Cross Blue Shield Association Bone Mineral Density Studies Medical Policy 6.01.01, 12/10/11.
  11. Blue Cross Blue Shield Association Vertebral Fracture Assessment with Densitometry Medical Policy 6.01.44, 01/12/12.
  12. Brunader R, Shelton DK. Radiologic bone assessment in the evaluation of osteoporosis. American Family Physician 2002; 65(7): 1357-1364.
  13. Charopoulos I, Tournis S, Trovas G et al. Effect of primary hyperparathyroidism on volumetric bone mineral density and bone geometry assessed by peripheral quantitative computed tomography in postmenopausal women. Journal of Clinical Endocrinology & Metabolism 2006; 91(5): 1748-1753.
  14. Cunny T, Ames R, Horne A et al. A Randomized Controlled Trial of Estrogen Replacement Therapy in Long-Term Users of Depot Medroxyprogesterone Acetate. The Journal of Clinical Endocrinology & Metabolism 2003; 88(1): 78-81.
  15. Florida Mandate Osteoporosis Prevention & Treatment, HB 397, 07/01/96.
  16. Florida Statute 627.6691 Coverage for Osteoporosis Screening, Diagnosis, Treatment, and Management, 2016.
  17. International Society for Clinical Densitometry (ISCD) Positions-Adults, 2 2013.
  18. National Osteoporosis Foundation Osteoporosis Bone Density Testing, 2017.
  19. Osteoporosis screening, diagnosis, treatment, and management Florida Statute 627.6691 (10/01/96), 2011.
  20. Rao SS, Budhwar N Ashfaque A. Osteoporosis in men. American Family Physician 2010; 82 (5), 503-508.
  21. Schousboe JT, Taylor BC, Fink HAF et al. Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men. The Journal of the American Medical Association 2007; 298(18): 2136-629-637.
  22. U.S. Preventive Services Task Force Screening for Osteoporosis, 2011.
  23. Wood K, Dhital S, Chen H et al. What is the clinical utility of distal forearm DXA in primary hyperparathyroidism? The Oncologist 2012.
  24. World Health Organization: What evidence is there for the prevention and screening of osteoporosis? May 2006.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/23/17.

GUIDELINE UPDATE INFORMATION:

08/15/96

Medical Coverage Guideline Developed.

04/17/00

Medical Coverage Guideline Reformatted.

01/01/02

HCPCS coding changes.

04/15/02

Revised description section of the guideline to include additional information about osteoporosis, bone mineral density studies. Changed bone densitometry to bone mineral density study. Added the National Osteoporosis Foundation (NOF) patient selection criteria for osteoporosis screening to the section entitled other. Added ultrasound densitometry to definition section. Updated references.

01/01/03

2003 CPT and HCPCS update.

09/30/03

Changed 3rd digit from 1 to 0 for diagnosis 252.1.

04/15/04

Annual Review. Added 5th digit to diagnosis code 256.31. Expanded diagnoses code range for other ovarian failure to include 256.31-256.39.

10/15/04

Revised reimbursement statement; deleted the word annually.

01/01/05

HCPCS update. Revised code 76075 descriptor. Added 76077.

02/15/06

Added “for individuals who have been taking hormone replacement therapy long-term (e.g., Depo-Provera) to when services are covered. Deleted ICD-9 diagnoses codes that support medical necessity. Added “wellness benefit” to when services are not covered. Added program exception (covered indications and ICD-9 codes that support medical necessity. Updated references.

08/15/06

Revised covered indications for bone mineral density studies: for individuals on long-term anticonvulsant therapy (e.g., phenytoin, Phenobarbital, Dilantin), for individuals on long-term luteinizing hormone releasing hormone agonist (e.g., Leuprolide, Goserelin). Deleted reference to Adult Preventive Services 01-99385-01 under RELATED GUIDELINES. Updated references.

09/15/06

Updated the NOF recommendation for measurement of bone mineral density (BMD).

11/15/06

Added code 76070, 76071, 76078, and 76877 to limitation of 1 of any type study per day and 1 of any type study in 12 months. Revised limitation for 76075, 76076, 76077, 78350, and 78351; changed to 2 of any type study per day and 2 of any type study in 12 months. Revised 627.2 code descriptor.

01/01/07

HCPCS update. Deleted 76070, 76071, 76075, 76076, 76077, 76877, and 76078. Added 77078, 77079, 77080, 77081, 77082, and 77083.

08/15/07

Reformatted guideline. Updated description section. Deleted Medicare Advantage products program exception. Updated references.

09/15/09

Annual review. Maintain position statements. Updated description. Added 76977 to reimbursement information section (1 of any type study in 12 month limit). Updated references.

01/01/12

Annual HCPCS coding update; deleted 77079 and 77083.

05/15/12

Guideline reviewed. Revised description. Reworded bone mineral density study medical necessity statement (added “central bone mineral density measurement”). Expanded position statement: added appropriateness criteria for peripheral bone mineral density measurement for primary hyperparathyroidism and screening for osteoporosis. Deleted 77079 and 77083. Revised reimbursement information; added statement regarding repeat, serial, documentation and imaging. Added LOINC codes. Revised definitions. Added cross-reference for Whole Body Dual X-ray Absorptiometry (DXA) to Determine Body composition and Other Body Composition Techniques, 04-70000-22. Revised wording for Florida statute for screening bone density measurement. Updated references.

05/11/14

Revision: Program Exceptions section updated.

01/01/15

Annual HCPCS code update. Deleted 77082. Added 77085 and 77086.

03/15/17

Revision; updated program exception and references.

Date Printed: December 18, 2017: 11:22 AM