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Clinical Policy Title: Bone mineral density measurement
Clinical Policy Number: 17.01.01
Effective Date: September 1, 2013
Initial Review Date: April 23, 2013
Most Recent Review Date: April 3, 2018
Next Review Date: April 2019
Related policies:
CP# 00.02.05 Agents for osteoporosis
ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.
Coverage policy
AmeriHealth Caritas considers the use of bone mineral density (BMD) measurement using dual-energy
X-ray absorptiometry (DXA/DEXA) to be clinically proven and, therefore, medically necessary for
members when at least one of the following clinical criteria and one of the following equipment criteria
are met (Schweiger 2016, International Society for Clinical Densitometry [ISCD] 2013 and 2015, Blain
2014, U.S. Preventive Services Task Force [USPSTF] 2011, Qaseem 2008):
Adults (ISCD 2015)
Women age 65 and older.
For post-menopausal women younger than age 65 a bone density test is indicated if they have a
risk factor for low bone mass such as;
o Low body weight
o Prior fracture
o High risk medication use
Policy contains:
Osteoporosis
Bone mineral density
measurement
Dual-energy X-ray
absorptiometry
Osteoporosis
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o Disease or condition associated with bone loss
Women during the menopausal transition with clinical risk factors for fracture, such as low body
weight, prior fracture, or high-risk medication use.
Men age 70 and older.
For men < 70 years of age a bone density test is indicated if they have a risk factor for low bone
mass such as;
o ◦Low body weight
o ◦Prior fracture
o ◦High risk medication use
o ◦Disease or condition associated with bone loss.
Adults with a fragility fracture.
Adults with a disease or condition associated with low bone mass or bone loss.
Adults taking medications associated with low bone mass or bone loss.
Anyone being considered for pharmacologic therapy.
Anyone being treated, to monitor treatment effect.
Anyone not receiving therapy in whom evidence of bone loss would lead to treatment.
Women discontinuing estrogen should be considered for bone density testing according to the
indications listed above.
Children and adolescents (ISCD 2013)
Children or adolescents with a finding of one or more vertebral compression fractures in the
absence of local disease or high-energy trauma.
Presence of both a clinically significant fracture history and BMD Z-score ≤ -2.0.
o A clinically significant fracture history is one or more of the following:
Two or more long bone fractures by age 10 years
Three or more long bone fractures at any age up to age 19 years.
The DXA measurement is part of a comprehensive skeletal health assessment
The DXA is performed when the DXA results will influence patient treatment interventions to
decrease their elevated risk of a clinically significant fracture.
Intervals between BMD testing should be determined according to each patient’s clinical status,
typically after initiation or change of therapy. (ISCD 2015).
In certain circumstances AmeriHealth Caritas considers BMD testing to be clinically proven and
therefore medically necessary, at a frequency more than once every 23 months, when at least 11
months have elapsed since the previous BMD measurement and testing is limited to the following:
An individual currently receiving pharmaceutical management with a glucocorticoid (steroid)
equivalent to an average of 5.0 mg of prednisone or greater per day for more than three
3
months.
Confirming baseline BMDs to permit monitoring of members when the initial BMD was not done
on the axial skeleton using a DXA/DEXA system. An individual being monitored to assess the
response to, or efficacy of, a U.S. Food and Drug Administration (FDA)-approved osteoporosis
drug therapy when performed with a DXA/DEXA system (axial skeleton) until, over time, a
response to such therapy has been documented.
AND
An AmeriHealth Caritas-approved and FDA-approved densitometer is used when the results of
the BMD study will be used in treatment decisions.
A peripheral BMD may be considered to be proven and medically necessary when an FDA-
approved densitometer is used for either of the following:
o An individual physically unable to undergo axial skeleton (hip/spine) measurements due
to physical size and surpassing the table limits for the DXA/DEXA device.
o Individuals diagnosed with hyperparathyroidism for whom a BMD of the forearm is
crucial to diagnosis.
All other uses of BMD testing not described within the context of this policy are considered to be
investigational and therefore not medically necessary, as their effectiveness is not supported by peer-
reviewed professional literature.
Limitations:
AmeriHealth Caritas considers the following to be limitations to this policy:
DXA/DEXA should not be performed if contractures prevent the safe and appropriate
positioning of the individual, especially in pediatric cases (ISCD 2013).
BMD measurement must include physician interpretation.
BMD testing should be performed at DXA/DEXA facilities using accepted quality assurance
measures.
AmeriHealth Caritas considers the following BMD tests to be investigational and therefore not medically
necessary, as the use of these tests is not supported by peer-reviewed professional literature:
Single-photon absorptiometry (CT code 78350).
Dual-photon absorptiometry (CPT 78351).
All other uses of BMD measurement are not medically necessary.
Alternative covered services:
Routine patient evaluation and management by a network healthcare provider
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Background
Bone strength is an important factor in an individual’s overall mobility and resistance to fractures and is
determined in part by bone density. Bone strength and density are determined by the mineral content
of a specified area as applied to size and shape (mass) of a bone. Low-density bones are less healthy,
more fragile, and prone to fractures. Osteoporosis is a disease marked by the progressive decrease in
bone density, increased fragility, and a susceptibility to bone fractures. Osteoporosis-related changes
occur when bone loss exceeds bone formation. Osteoporotic changes in the bones are commonly found
in postmenopausal women; however, they are seen in both genders and all people of advancing age.
Secondary osteoporosis may be caused by conditions that impair the intake and utilization of nutrients,
such as anorexia nervosa, bariatric surgery, or prolonged steroid drug treatment.
BMD tests are noninvasive, used to identify individuals with osteoporosis, and may be used to monitor
response to osteoporosis treatments. The goal of detecting a low BMD in an individual is to assist with
the decision-making toward treatment to prevent a fragility (osteoporotic) fracture. The risk-predicting
ability of BMD studies has been compared to the use of cholesterol testing to predict hypertension and
heart disease. BMD studies are radiologic or radioisotopic and are performed with an FDA-approved
bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer
system. The gold standard and most widely used method for BMD is DXA/DEXA.
DEXA requires a short scan time and is used to provide extremely precise and reproducible BMD
measurement. The preferred DEXA measurement sites are located on the central skeleton; these are the
total hip, femoral neck, total lumbar spine, or some combination of these sites. Central skeletal sites are
preferred for baseline and serial BMD measurements and are also more likely than peripheral skeletal
sites to show a response to treatment. Examples of peripheral skeletal sites are the wrist, finger,
forearm, or heel. Peripheral testing only uses one site, and this may be problematic because of
differences in bone density between different skeletal sites. Low bone densities in other skeletal areas
may be overlooked. It is important to note that the diagnostic criteria established by the WHO and
recommendations by the American Association of Clinical Endocrinologists (AACE) apply only to the
peripheral radius site and central (total hip, femoral neck, lumbar spine) site DEXA measurements
(AACE, 2010).
Other BMD techniques use both the central and skeletal sites. In addition to DEXA, the established
methods for BMD testing are the following:
Quantitative computed tomography (QCT).
Radiographic absorptiometry (RA; photodensitometry).
Single-energy X-ray absorptiometry (SEXA).
Ultrasound BMD studies (i.e., bone sonometry).
Quantitative computed tomography is a three-dimensional BMD test that also uses both central and
peripheral skeletal sites. The measurement is calculated using the differential absorption of ionizing
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radiation by calcified (bone) tissue. It is the only technique that can distinguish between cortical and
cancellous bone and may use standard CT scanners. However, it is expensive, is not widely available, and
uses a relatively high amount of radiation exposure. Radiographic absorptiometry uses plain radiographs
of peripheral sites, most commonly from the hand or heel. Its use decreased as other precise
nonradiographic techniques became available. Single-photon absorptiometry (SPA) uses a single-energy
beam usually passed through the wrist to provide a quantitative measurement of bone mineral and
trabecular bone. Dual-photon absorptiometry measures BMD by the absorption of a dichromatic beam
by bone material, and has limited usefulness in monitoring BMD changes. In current practice, these
methods are rarely used. In particular, dual-photon absorptiometry may be considered obsolete.
Searches
AmeriHealth Caritas searched PubMed and the databases of:
UK National Health Services Centre for Reviews and Dissemination.
Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on February 13, 2018. Search terms were “bone measurement,” “osteoporosis,”
“menopause,” and “DEXA” (MeSH).
We included:
Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and
greater precision of effect estimation than in smaller primary studies. Systematic reviews use
predetermined transparent methods to minimize bias, effectively treating the review as a
scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
Guidelines based on systematic reviews.
Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost
studies), reporting both costs and outcomes — sometimes referred to as efficiency studies —
which also rank near the top of evidence hierarchies.
Findings
Various clinical and special interest organizations have published clinical guidelines for osteoporosis and
BMD testing. However, at the writing of this policy, no single unifying consensus statement has been
formulated. All professional societies acknowledge the aging of the U.S. population will likely lead to an
increase in cases of osteoporosis. BMD testing could detect osteoporosis in a large portion of the
population and may prevent many fractures and fracture-related illnesses in this population.
The studies and national guidelines below recommend screening for osteoporosis in women age 65 or
older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white
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woman with no additional risks. The examination may be performed using either single-photon or dual-
photon absorptiometry. A higher frequency of testing (i.e., more often than every 23 months) has not
been demonstrated to improve outcomes.
Osteoporosis is diagnosed by using the globally accepted World Health Organization (WHO) definition of
BMD measurement and fracture risk assessment. The WHO definition of osteoporosis is based on a
bone mineral density 2.5 standard deviations (-2.5 T-score) below the mean found in young, healthy
adults. Bone mass measurements are performed to identify bone mass (mineral density), detect bone
loss, or determine bone quality. The WHO has developed the fracture risk assessment (FRAX®), a tool
used to combine the risks associated with a femoral neck BMD and other clinical risk factors for an
evaluation of an individual’s overall fracture risk. This computer-based tool, available on the WHO
website, also has several simplified paper versions. Access to the web-based tool enables calculations
for the major races found on each continent. FRAX® algorithms are used to assess an individual’s 10-
year fracture probability for both femoral and other major osteoporotic fractures (clinical spine,
forearm, hip, or shoulder fracture).
The United States Preventative Services Task Force (USPSTF) recommendations for BMD testing include
all racial and ethnic groups for women age 65 and older, as the consequences of failing to identify and
treat women with low BMD are significant. The same recommendations do not define an upper age limit
for screening women because of the increased risk for fractures with the advancement in age and the
fact that treatment harms remain small. These same guidelines recommend women under age 65 who
have a fracture risk greater than or equal to that of a 65-year-old white woman also be screened for
BMD (USPSTF 2011). The American College of Physicians states that high-quality evidence shows that
age, low body weight, physical inactivity, and weight loss are strong predictors of an increased risk for
osteoporosis in men (ACOP 2008).
The National Osteoporosis Foundation (NOF) 2013 recommendations include both men and women.
The NOF agrees with the USPSTF recommendation that women age 65 and older should be screened,
and adds recommendations that men age 70 and older be tested regardless of risk factors. The NOF
further provides indications for bone mineral testing for men between the ages of 50 and 69. The 2013
updated NOF Clinician’s Guide stresses the importance of screening vertebral imaging to diagnose
asymptomatic vertebral fractures; provide updated information on calcium, vitamin D and osteoporosis
medications; and address treatment durations.
Skeletal health in children between the ages of 5 and 19 is assessed by the use of fracture prediction and
definition of osteoporosis. Fracture prediction is the identification of significant fractures of the long
bones, vertebral compression fractures, or two or more long bone fractures of the upper body. A
diagnosis of osteoporosis in children is not made solely on the basis of densitometric criteria. The
diagnosis must take into account the clinically significant fracture history and BMD or low bone mineral
content (BMC). Low BMD or BMC is defined by the presence of a BMC or BMD Z-score less than or equal
to -2.0, adjusted for the child’s gender, age, and body size (ISCD 2015).
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Policy updates:
A systematic review and meta-analysis (Schweiger, 2016) evaluated the evidence of low bone mineral
density (BMD) in 1,842 depressed and 17,401 nondepressed individuals. Significant negative composite
weighted mean effect sizes were identified for the lumbar spine (d = -0.15, 95%CL -0.22 to -0.08), femur
(d = -0.34, 95%CL -0.64 to -0.05), and total hip (d = -0.14, 95%CL -0.23 to -0.05) indicating low BMD in
depression. Examining men and women showed low bone density in the lumbar spine and femur in
women and low bone density in the hip in men. The differences between men and women with mineral
density deficit (MDD) and the comparison group tended to be higher when examined by expert
interviewers. Low bone density was found in all age groups. The authors concluded that bone mineral
density is reduced in patients with depressive disorders.
During the interval since our last update further information has come forward regarding testing for
BMD.
A systematic review (Blain 2014) assessed whether a fall within the past year should trigger automatic
BMD testing. The premise was based on estimations of osteoporosis and fall risk, studies that cite
fracture risk is independent from fall risk, that osteoporosis drugs have been proven effective in
preventing fracture in people with osteoporosis, and the prevalence of osteoporosis is high in patients
who fall and increases in the presence of markers for frailty (e.g., recurrent falls, sarcopenia [low muscle
mass and strength], limited mobility, and weight loss). The authors noted that life expectancy should be
taken into account when assessing the appropriateness of BMD in fallers, as osteoporosis treatments
require at least 12months to decrease the fracture risk. Other factors that impact the management of
fallers include the availability of testing sites, which may be limited due to geographic factors, patient
dependency, or severe cognitive impairments.
Summary of clinical evidence:
Citation Content, Methods, Recommendations
Schweiger (2016)
Bone density and
depressive
disorder: a meta-
analysis
Key points:
Systematic review and meta-analysis of 1,842 depressed and 17,401 nondepressed
individuals.
Significant negative composite weighted mean effect sizes were identified for the lumbar
spine (d = -0.15, 95%CL -0.22 to -0.08), femur (d = -0.34, 95%CL -0.64 to -0.05), and total
hip (d = -0.14, 95%CL -0.23 to -0.05) indicating low BMD in depression.
Examining men and women showed low bone density in the lumbar spine and femur in
women and low bone density in the hip in men.
Differences between men and women with MDD and the comparison group tended to be
higher when examined by expert interviewers.
Low bone density was found in all age groups.
The authors concluded that bone mineral density is reduced in patients with depressive
disorders.
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Citation Content, Methods, Recommendations
ISCD (2015)
Official Positions
2015: adults
Key points:
Adult Official Positions of the ISCD as updated in 2015 define the indications for BMD
testing:
o Women aged 65 and older
o For post-menopausal women younger than age 65 a bone density test is indicated
if they have a risk factor for low bone mass such as; ◦Low body weight
Prior fracture
High risk medication use
Disease or condition associated with bone loss.
o Women during the menopausal transition with clinical risk factors for fracture, such
as low body weight, prior fracture, or high-risk medication use.
o Men aged 70 and older.
o For men < 70 years of age a bone density test is indicated if they have a risk factor
for low bone mass such as; ◦Low body weight
Prior fracture
High risk medication use
Disease or condition associated with bone loss.
o Adults with a fragility fracture.
o Adults with a disease or condition associated with low bone mass or bone loss.
o Adults taking medications associated with low bone mass or bone loss.
o Anyone being considered for pharmacologic therapy.
o Anyone being treated, to monitor treatment effect.
o Anyone not receiving therapy in whom evidence of bone loss would lead to
treatment.
Women discontinuing estrogen should be considered for bone density testing according to
the indications listed above.
Intervals between BMD testing should be determined according to each patient’s clinical
status, typically after initiation or change of therapy.
Blain (2014)
Usefulness of bone
density
measurement in
fallers.
Key points:
Systematic review assessed whether a fall within the past year should trigger automatic BMD
testing.
The premise was based on estimations of osteoporosis and fall risk, studies that cite fracture
risk is independent from fall risk, that osteoporosis drugs have been proven effective in
preventing fracture in people with osteoporosis, and the prevalence of osteoporosis is high in
patients who fall and increases in the presence of markers for frailty (e.g., recurrent falls,
sarcopenia [low muscle mass and strength], limited mobility, and weight loss).
The authors noted that life expectancy should be taken into account when assessing the
appropriateness of BMD in fallers, as osteoporosis treatments require at least 12months to
decrease the fracture risk.
Other factors that impact the management of fallers include the availability of testing sites,
which may be limited due to geographic factors, patient dependency, or severe cognitive
impairments.
ISCD (2013)
Key points:
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Citation Content, Methods, Recommendations
Official Positions
2013: children and
adolescents
Skeletal health in children between the ages of 5 and 19 is assessed by the use of fracture
prediction and definition of osteoporosis.
Fracture prediction is the identification of significant fractures of the long bones, vertebral
compression fractures, or two or more long bone fractures of the upper body.
A diagnosis of osteoporosis in children is not made solely on the basis of densitometric
criteria.
The diagnosis must take into account the clinically significant fracture history and BMD or low
bone mineral content (BMC).
Low BMD or BMC is defined by the presence of a BMC or BMD Z-score less than or equal to
-2.0, adjusted for the child’s gender, age, and body size.
USPSTF (2011)
The U.S.
Preventive
Services Task
Force updated its
2002
recommendation
on screening for
osteoporosis.
Key points:
The USPSTF evaluated evidence on the diagnostic accuracy of risk assessment instruments
for osteoporosis and fractures, the performance of DEXA and peripheral bone measurement
tests in predicting fractures, the harms of screening for osteoporosis, and the benefits and
harms of drug therapy for osteoporosis in women and men.
The USPSTF recommends screening for osteoporosis in women age 65 older and in
younger women whose fracture risk is equal to or greater than that of a 65-year-old white
woman who has no additional risk factors (Grade B recommendation).
The USPSTF concluded the current evidence is insufficient to assess the balance of benefits
and harms of screening for osteoporosis in men.
Qaseem et al.
(2008)
A clinical practice
guideline on
osteoporosis in
men issued by the
American College
of Physicians
(ACP)
Key points:
Recommended physicians periodically assess elderly men for risk factors for osteoporosis.
Although osteoporosis is often viewed as a disease of women, studies show osteoporotic
fractures in men are associated with significant morbidity and mortality, resulting in
substantial disease burden, death, and health care costs.
The prevalence of osteoporosis is estimated to be 7% in white men, 5% in black men, and
3% in Hispanic men. Data on prevalence of osteoporosis in Asian-American men and other
ethnic groups is lacking.
The guideline recommended that clinicians assess risk factors for osteoporosis in older men
and obtain a DXA scan for men at increased risk for osteoporosis who are candidates for
drug therapy.
Risk factors for osteoporosis in men include age greater than 70; low body weight (BMI less
than 20 to 25 kg/m2); weight loss (greater than 10%); lack of regular physical activity such as
walking, climbing stairs, carrying weights, housework, or gardening; use of oral
corticosteroids; previous osteoporotic fracture; and androgen deprivation therapy.
ACP also recommended further research to evaluate osteoporosis screening tests in men
and that, presently, non-DXA tests are either "too insensitive or have insufficient data to
reach conclusions.”
References
Professional society guidelines/other:
American Association of Clinical Endocrinologists (AACE) Osteoporosis Task Force. AACE Medical
Guidelines for Clinical Practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr
10
Pract. 2010;16(3): 1 – 37. Also available on the AACE website at https://www.aace.com/files/osteo-
guidelines-2010.pdf. Accessed February 13, 2018.
American College of Radiology (ACR). ACR-SSR Practice Guidelines for the performance of Dual-Energy X-
ray Absorptiometry (DXA). Revised 2008. [ACR website.] Available at https://www.acr.org/-
/media/ACR/Files/Practice-Parameters/dxa.pdf?la=en. Accessed February 13, 2018.
American College of Radiology (ACR). ACR Appropriateness criteria for Osteoporosis and Bone Mineral
Density. Original 1998. Amended 2014. [ACR website.] https://acsearch.acr.org/docs/69358/Narrative/
f. Accessed February 13, 2018.
The Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of osteoporosis.
Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). Revised 2016. www.guideline.gov/.
Accessed February 13, 2018.
International Society for Clinical Densitometry (ISCD). Official Positions 2013. Children and adolescents.
ISCD website. https://www.iscd.org/official-positions/2013-iscd-official-positions-pediatric/. Accessed
February 13, 2018.
International Society for Clinical Densitometry (ISCD). Official Positions 2015. Adult. ISCD website.
https://www.iscd.org/official-positions/2015-iscd-official-positions-adult/ . Accessed February 13, 2018.
National Osteoporosis Foundation (NOF). Clinicians guide to prevention and treatment of osteoporosis.
[NOF website.] Original 2008. Revised January 2013. Available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4176573/. Accessed February 13, 2018.
Qaseem A, Snow V, Shekelle P, et al. Clinical Efficacy Assessment Subcommittee of the American College
of Physicians (ACP). Screening for osteoporosis in men: a clinical practice guideline from the American
College of Physicians. Ann Intern Med. 2008;148(9):680 – 84. [ACP website.]
Rosen DS, the American Academy of Pediatrics Committee on Adolescence. Identification and
management of eating disorders in children and adolescents. Pediatrics. Revised 2010;26(6):1240 –
1253. Available at http://pediatrics.aappublications.org/content/126/6/1240.full.pdf. Accessed February
13, 2018.
Peer-reviewed references:
American Academy of Orthopaedic Surgeons (AAOS). Osteoporosis tests. Rev. 2007 [AAO website].
Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00413. February 13, 2018.
Bae DC, Stein BS. The diagnosis and treatment of osteoporosis in men on androgen deprivation therapy
for advanced carcinoma of the prostate. J Urol. 2004;172(6 Pt 1):2137 – 2144.
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Bell KJ, Hayen A, Macaskill P, et al. Value of routine monitoring of bone mineral density after starting
bisphosphonate treatment: secondary analysis of trial data. BMJ. 2009; 338:b2266.
Berger C, Langsetmo L, Joseph L, et al. Canadian Multicentre Osteoporosis Study Research Group.
Change in bone mineral density as a function of age in women and men and association with the use of
antiresorptive agents. CMAJ. 2008;178(13):1660 – 1668.
Berger C, Langsetmo L, Joseph L, et al. Association between change in BMD and fragility fracture in
women and men. J Bone Miner Res. February 2009;361 – 379.
Blain H, Rolland Y, Beauchet O, et al.; Groupe de recherche et d’information sur les ostéoporoses et la
Société française de gérontologie et gériatrie. Usefulness of bone density measurement in fallers. Joint
Bone Spine. 2014 Oct;81(5):403-8. doi: 10.1016/j.jbspin.2014.01.020. Epub 2014 Apr 2. Review. PubMed
PMID: 24703626.
Blake GM, Fogelman I. An update on dual-energy x-ray absorptiometry. Semin Nucl Med. 2010
Jan;40(1):62 – 73.
Carrasco F, Ruz M, Rojas P, et al. Changes in bone mineral density, body composition and adiponectin
levels in morbidly obese patients after bariatric surgery. Obes Surg. 2009;19(1):41 – 46.
Fleischer J, Stein EM, Bessler M, et al. The decline in hip bone density after gastric bypass surgery is
associated with extent of weight loss. J Clin Endocrinol Metab. 2008;93(10):3735 – 3740.
Frost SA, Nguyen ND, Center JR, et al. Timing of repeat BMD measurements: development of an
absolute risk-based prognostic model. J Bone Miner Res. 2009;24(11):1800 – 1807.
Gourlay M, Fine J, Preisser J, et al. Bone-Density Testing Interval and Transition to Osteoporosis in Older
Women. New Engl J Med. January 2012. 225-233.
Kanis JA, McCloskey EV, Johansson H, Strom O, Borgstrom F, Oden A.; National Osteoporosis Guideline
Group Case finding for the management of osteoporosis with FRAX—assessment and intervention
thresholds for the UK. Osteoporosis Int. 2008;19:1395 – 408.
http://www.ncbi.nlm.nih.gov/pubmed/12057569. Accessed February 28, 2017.
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Juvenile osteoporosis.
[NIAMS website.] June 2015.
http://www.niams.nih.gov/Health_Info/Bone/Bone_Health/Juvenile/juvenile_osteoporosis.asp.
Accessed February 13, 2018.
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Osteoporosis in men.
[NIAMS website.] Reviewed January 2012. Available at
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http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/men.asp. Accessed February 13, 2018.
National Osteoporosis Foundation (NOF). Detecting Osteoporosis. [NOF website.] 2011. Available at:
http://www.nof.org/aboutosteoporosis/detectingosteoporosis/diagnosing. Accessed February 13, 2018.
Nelson HD, Haney EM, Chou R, et al. Screening for Osteoporosis: Systematic Review to Update the 2002
U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 77. AHRQ Publication No.
10-05145-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality, July 2010. Available at
http://www.ncbi.nlm.nih.gov/books/NBK45201/pdf/TOC.pdf. Accessed February 13, 2018.
North American Menopause Society. Management of osteoporosis in postmenopausal women. [NAMS
website]. 2010. Available at: http://www.menopause.org/docs/default-document-
library/psosteo10.pdf?sfvrsn=2. Accessed February 13, 2018.
Qaseem A, Snow V, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College
of Physicians. Screening for osteoporosis in men: A clinical practice guideline from the American College
of Physicians. Ann Intern Med. 2008;148(9):680 – 684.
Schweiger JU, Schweiger U, Hüppe M, Kahl KG, Greggersen W, Fassbinder E. Bone density and
depressive disorder: a meta-analysis. Brain Behav. 2016;6(8):e00489.
U.S. Preventive Services Task Force (USPSTF). Screening for osteoporosis in postmenopausal women.
[USPTF website.] January 2011.
http://www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.pdf. Accessed February
13, 2018.
Valderas JP, Velasco S, Solari S, et al. Increase of bone resorption and the parathyroid hormone in
postmenopausal women in the long-term after Roux-en-Y gastric bypass. Obes Surg. 2009;19(8):1132 –
1138.
Vilarrasa N, San Jose P, Garcia I, et al. Evaluation of bone mineral density in morbidly obese women after
gastric bypass: 3-year follow-up. Obstet Surg. 2010 [Epub ahead of print].
CMS National Coverage Determinations (NCDs):
150.3 Bone mineral density testing. CMS website https://www.cms.gov/medicare-coverage-
database/details/ncd-
details.aspx?NCDId=256&ncdver=2&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&
KeyWord=bone+mineral+density&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAA
AA& Accessed February 13, 2018
Local Coverage Determinations (LCDs):
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L36356 Bone mineral density testing. CMS website https://www.cms.gov/medicare-coverage-
database/details/lcd-
details.aspx?LCDId=36356&ver=19&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&
KeyWord=bone+mineral+density&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAA
AA&. Accessed February 13, 2018.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is
not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and
bill accordingly.
CPT Code Description Comments
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 (e.g., hips, pelvis, spine), including vertebral fracture
assessment
77086 Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)
ICD-10 Code Description Comments
C90.00-C90.02 Multiple myeloma
D56.0 Alpha thalassemia
D56.1 Beta thalassemia
D56.8 Other thalassemias
E01.1 Iodine-deficiency related multinodular (endemic) goiter
E04.1 Nontoxic single thyroid nodule
E04.2 Nontoxic multinodular goiter
E04.8 Other specified nontoxic goiter
E04.9 Nontoxic goiter, unspecified
E05.90 Thyrotoxicosis
E07.9 Disorder of thyroid, unspecified
E21.0 Primary hyperparathyroidism
E28.310 Symptomatic premature menopause
E28.319 Asymptomatic premature menopause
E28.39 Other primary ovarian failure
E29.1 Hypogonadism, male
E34.2 Ectopic hormone secretion, not elsewhere classified
E55.9 Vitamin D deficiency, unspecified
E58 Dietary calcium deficiency
14
ICD-10 Code Description Comments
E72.0 Disorder of urea cycle metabolism
E10.1-E10.9 Diabetes Type I
E46 Malnutrition
E83.118 Other hemochromatosis
E83.119 Hemochromatosis, unspecified
E83.39 Hypophosphatasia
E84.0-E84.9 Cystic fibrosis
F10.10 Alcohol abuse
K76.9 Chronic liver disease
K90.9 Malabsorption
M06.0-M06.9 Rheumatoid arthritis
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e),
initial encounter for fracture
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial
encounter for fracture
M83.0 Puerperal osteomalacia
M83.1 Senile osteomalacia
M83.2 Adult osteomalacia due to malabsorption
M83.3 Adult osteomalacia due to malnutri
M83.4 Aluminum bone disease
M83.5 Other drug-induced osteomalacia in adults
M83.8 Other adult osteomalacia
M83.9 Adult osteomalacia, unspecified
M85.80-M85.9 Osteopenia
N91.0 Exercise induced amenorrhea
N91.5 Oligomenorrhea
Q78.0 Osteogenesis imperfecta
Z13.820 Encounter for screening for osteoporosis
Z68.20 Body mass index (BMI) 19 or less, adult
Z68.21 Body mass index (BMI) 20-20.9, adult
Z72.0 Tobacco use
Z78.0 Asymptomatic menopausal state
Z79.3 Long term (current) use of hormonal contraceptives
Z79.51 Long term (current) use of inhaled steroids
Z79.52 Long term (current) use of systemic steroids
Z79.891 Long term (current) use of opiate analgesic
Z79.899 Other long term (current) drug therapy
Z82.62 Family history of osteoporosis
Z87.310 Personal history of (healed) osteoporosis fracture
Z87.311 Personal history of (healed) other pathological fracture
Z87.81 Personal history of vertebral fracture, healed
Z90.722 Acquired absence of ovaries, bilateral
15
HCPCS
Level II Code Description Comments
N/A
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