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Date Printed: October 20, 2017: 02:05 PM

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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.

04-70000-22

Original Effective Date: 03/15/04

Reviewed: 02/23/17

Revised: 03/15/17

Subject: Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition and Other Body Composition Techniques

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:

Measurements of body composition have been used to study how lean body mass and body fat change during health and disease. Also, measurements of body compositions have provided a research tool to study the metabolic effects of aging, obesity and various wasting conditions such as occurs with AIDS or post- bariatric surgery. A variety of techniques have been researched, including anthropomorphic measures, bioelectrical impedance, and dual X-ray absorptiometry (DEXA or DXA) scans. All of these techniques are based in part on assumptions regarding the distribution of different body compartments and their density, and all rely on formulas to convert the measured parameter into an estimate of body composition. All techniques will introduce variation based how the underlying assumptions and formulas apply to different populations of subjects (e.g., different age groups, ethnicities, or underlying conditions). Anthropomorphic, bioelectrical, underwater weighing and DEXA techniques are briefly reviewed as followed.

Anthropomorphic Techniques

Anthropomorphic techniques for the estimation of body composition include measurements of skin-fold thickness at various sites, bone dimensions, and limb circumference. These measurements are used in various equations to predict body density and body fat. Due to its ease of use, measurements of skin-fold thickness are one of the most commonly used techniques. The technique is based on the assumption that the subcutaneous adipose layer reflects total body fat, but this association may vary with age and gender.

Bioelectrical Impedance

Bioelectrical impedance is based on the relationship between the volume of the conductor (e.g., the human body), the conductor’s length (e.g., height), the components of the conductor (e.g., fat and fat-free mass), and its impedance. Estimates of body composition are based on the assumption that the overall conductivity of the human body is closely related to lean tissue. The impedance value is combined with anthropomorphic data to give body compartment measures. This technique involves attaching surface electrodes to various locations on the arm and foot. Alternatively, the patient can stand on pad electrodes.

Underwater Weighing

Underwater weighing (UWW) has generally been considered the reference standard for body composition studies. This technique requires the use of a specially constructed tank in which the subject is seated on a suspended chair. The subject is then submerged in the water while exhaling. While valued as a research tool, UWW is not suitable for routine clinical use. UWW is based on the assumption that the body can be divided into 2 compartments with constant densities, i.e., adipose tissue with a density of 0.9gm/cm3 and lean body mass (e.g., muscle and bone) with a density of 1.1g/cm3. One limitation of the underlying assumption is the variability in density between muscle and bone; for example, bone has a higher density than muscle, and bone mineral density varies with age and other conditions. In addition, the density of body fat may vary, depending on the relative components of its constituents (e.g., glycerides, sterols, glycolipids).

DEXA

While the above techniques assume 2 body compartments, dual energy X-ray absorptiometry can estimate 3 body compartments consisting of fat mass, lean body mass, and bone mass. DEXA systems use a source that generates X-rays at 2 energies. The differential attenuation of the 2 energies is used to estimate the bone mineral content and the soft tissue composition. When 2 X-ray energies are used, only 2 tissue compartments can be measured; therefore, soft tissue measurements (e.g., fat and lean body mass) can only be measured in areas where no bone is present. DEXA also has the ability to determine body composition in defined regions, (e.g., in the arms, legs, trunk). DEXA measurements are based in part on the assumption that the hydration of fat-free mass remains constant at 73%. Hydration, however, can vary from 67% – 85%, and can be variable in certain disease states.

POSITION STATEMENT:

Whole body dual x-ray absorptiometry (DEXA, DXA) for body composition studies and testing are considered experimental or investigational, as there is insufficient evidence to support the use of DEXA/DXA on health outcomes.

The determination of body composition is considered experimental or investigational, for all indications, including, but not limited to the following, as there is insufficient evidence to support the use of body composition techniques on health outcomes.

BILLING/CODING INFORMATION:

There is no specific CPT or HCPCS code that describes whole body dual x-ray absorptiometry (DEXA/DXA) and other body composition techniques to determine body composition.

The following code may be used to describe bioelectrical impedance analysis (BIA) whole body composition assessment.

CPT Coding:

0358T

Bioelectrical impedance analysis whole body composition assessment, with interpretation and report (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date. Dual energy x-ray absorptiometry [DEXA] body composition study, one or more sites, is included in the First Coast Service Options, Inc. LCD for The List of Medicare Noncovered Services L33777.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

For DEXA or DXA bone density study, see Bone Mineral Density Studies 04-70000-21.
For Thoracic Electrical Bioimpedance (TEB), see Thoracic Electrical Bioimpedance (TEB) 01-93000-29.

OTHER:

None applicable.

REFERENCES:

  1. American Heart Association. Body Composition Tests, 2009.
  2. Blue Cross Blue Shield Association Medical Policy-Whole Body Dual X-Ray Absorptiometry (DEXA) to Determine Body Composition 6.01.40, 2015.
  3. Braillon PM, Serban A. Bone mineral content and body composition in overweight children and adolescents. Pediatric Research 2007; 62(4): 462-467.
  4. Delpierre C, Bonnet E, Marion-Latard F et al. Impact of HIV infection on total body composition in treatment-naive men evaluated by dual-energy X-ray absorptiometry comparison of 90 untreated HIV-infected men to 241 controls. Journal of Clinical Densitometry 2007; 10(4): 376-380.
  5. Dewit O, Fuller NJ, Fewtrell MS et al. Whole body air displacement plethysmography compared with hydrodensitometry for body composition analysis. Archives of Disease in Childhood 2000; 82; 159-164.
  6. Elkan AC, Engvall IL, Tengstrand B et al. Malnutrition in women with rheumatoid arthritis is not revealed by clinical anthropometrical measurements or nutritional evaluation tools. European Journal of Clinical Nutrition 2008; 62(10): 1239-1247.
  7. Forrester JE, Sheehan HM, Joffe TH. A validation study of body composition by bioelectrical impedance analysis in human immunodeficiency virus (HIV)-positive and HIV-negative Hispanic men and women. Journal of the American Dietetic Association 2008; 108(3): 534-538.
  8. Haderslev KV, Jeppesen PB, Sorensen HA et al. Body composition measured by dual-energy X-ray absorptiometry in patients who have undergone small-intestinal resection. The American Journal of Clinical Nutrition 2003; 78(1): 78-83.
  9. Jebb SA, Siervo M, Murgatroyd PR et al. Validity of the leg-to-leg bioimpedance to estimate changes in body fat during weight loss and regain in overweight women: a comparison with multi-compartment models. International Journal of Obesity 2007; 31(5): 756-762.
  10. Kohrt WM. Premiminary Evidence that DEXA Provides an Accurate Assessment of Body Composition. Journal of Applied Physiology 1998; 84: 372-377.
  11. LaForgia J, Dollman J, Dale MJ et al. Validation of DXA body composition estimates in obese men and women. Obesity 2009; 17(4): 821-826.
  12. Monteiro PA, Antunes BM, Silveira LS, et al. Body composition variables as predictors of NAFLD by ultrasound in obese children and adolescents. BMC Pediatrics 2014;14:25.
  13. Moyer VA. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal of Medicine 2012; 157(5): 373.378.
  14. Plasqui F, den Hoed M, Bonomi A et al. Body composition in 10 – 13-year-old children: A comparison between air displacement plethysmography and deuterium dilution. International Journal of Pediatric Obesity 2009; 15: 1-8.
  15. Prior BM, Cureton KJ, Modlesky XM et al. In Vivo Validation of Whole Body Composition Estimates from Dual-Energy X-ray Absorptiometry. Journal of Applied Physiology 1997; 83:623-630.
  16. Sala A, Webber CE, Morrison J et al. Whole body mineral content, lean body mass, and fat mass measured by dual-energy X-ray absorptiometry in a population of normal Canadian children and adolescents. Canadian Association of Radiologists Journal 2007; 58(1): 46-52.
  17. Salamone LM, Fuerst T, Visser M et al. Measurement of fat mass using DEXA: a validation study in elderly adults. Journal of Applied Physiology 2000; 89(1): 345-52.
  18. Smith EE, Hudson J, Martin A et al. Centralized Assessment of Dual-Energy X-ray Absorptiometry (DEXA) in Multicenter Studies of HIV-Associated Lipodystrophy 2003; 4(1): 45-49.
  19. Tsekes G, Chrysos G, Douskas G et al. Body Composition Changes in Protease Inhibitor-Naïve HIV-infected Patients Treated with Two Nucleoside Reverse Transcriptase Inhibitors 2002; 3:85-90.
  20. US Preventive Services Task Force. Screening for obesity in children and adolescents: US Preventives Services Task Force recommendation statement. Pediatrics 2010; 125 (2): 361-367.
  21. Valerio CM, Godoy-Matos A, Moreira RO et al. Dual-Energy X-Ray Absorptiometry Study of Body Composition in Patients with Lipodystrophy. Diabetes Care 2007; 30(7); 1857-1859.
  22. Ziai S, Coriati A, Chabot K, et al. Agreement of bioelectric impedance analysis and dual-energy X-ray absorptiometry for body composition evaluation in adults with cystic fibrosis. Journal of Cystic Fibrosis 2014;13(5):585-588.

COMMITTEE APPROVAL:

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

GUIDELINE UPDATE INFORMATION:

03/15/04

New Medical Coverage Guideline.

12/15/04

Scheduled review. No change in investigational status. Updated references.

01/01/06

Scheduled review. No change in investigational status. Updated references.

09/15/06

Scheduled review. No change in investigational status. Added cross-reference to the Bone Mineral Density Studies Medical Coverage Guideline. Updated references.

08/15/07

Annual review, investigational status maintained, guideline reformatted, references updated.

09/15/08

Scheduled review. No change in position statement. Updated references. Added investigational statement back to ICD-9 diagnoses codes that support medical necessity.

01/01/09

Annual HCPCS coding update: deleted code 0028T.

09/15/09

Annual review. Added “and other body composition techniques” to MCG subject. Revised whole body DEXA position statement. Added position statement for other body composition techniques. Added related guideline link for thoracic electrical bioimpedance (TEB) guideline. Updated references.

09/15/11

Annual review; maintain experimental or investigational position statement. Updated references.

12/15/13

Annual review; maintain experimental or investigational position statement. Add Medicare Advantage products program exception. Updated references.

07/01/14

Quarterly HCPCS update; added 0358T.

11/01/15

Revision: ICD-9 Codes deleted.

01/01/16

Annual HCPCS code update. Revised 0358T code descriptor.

03/15/17

Revision; updated references.

Date Printed: October 20, 2017: 02:05 PM