Bone mineral density (BMD) testing is a widely available clinical tool for screening and diagnosing osteoporosis. These studies are also used to predict fracture risk and monitor response to therapy. Bone mineral density can be measured using different techniques in a variety of central (i.e., hip or spine) or peripheral (i.e., wrist, finger, heel) sites.
The following technologies are most commonly used to measure BMD.
Dual-energy x-ray absorptiometry — (DXA) is recommended by the National Osteoporosis Foundation (NOF) for bone density test of the spine, hips and pelvis to diagnose osteoporosis. When testing testing cannot be done on the spine, hips and pelvis, NOF suggests a central DXA test of the radius bone in the forearm. DXA can also be used to measure peripheral sites, such as the wrist and finger. DXA is non- invasive and provides precise measurements of bone density with minimal radiation.
Portable Peripheral Bone Density testing — portable devices that can determine BMD at peripheral sites such as the radius, phalanges, or calcaneus.
Single Photon Absorptiometry (SPA) and Dual-Photon Absorptiometry (DPA) — measure bone mineral content at the distal radius (SPA) and the spine and hip (DPA) using photons emitted at low energy levels.
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.)
Frequency Guidelines
Coverage for eligible bone density studies is limited to one (1) test every two (2) years 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 may be considered medically necessary under the following circumstances:
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 two (2) years frequency limitation and the diagnosis or condition not meeting the expanded criteria described above, it will be denied as not medically necessary.
General Coverage Guidelines
Bone density studies may be considered medically necessary for ANY ONE of the following indications:
DXA for pediatrics (until age 19) may be considered medically necessary when ANY ONE of the following is met:
The provider must submit medical records and/or additional documentation to determine coverage in the above situations.
Bone density studies not meeting the criteria as indicated in this policy are considered not medically necessary.
77078 |
77080 |
77081 |
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Single Photon Absorptiometry (SPA), Dual-Photon Absorptiometry (DPA), and radiographic absorptiometry (i.e., photodensitometry, radiogrammetry) are considered not medically necessary.
78350 |
78351 |
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|
|
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BMD measurement using ultrasound densitometry and/or quantitative computed tomography are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
0508T |
0554T |
0555T |
0556T |
0557T |
0558T |
0743T |
0749T |
0750T |
|
|
|
|
|
Covered Diagnosis Codes for Procedure Codes: 77078, 77080, and 77081
C75.1 |
C75.2 |
D35.2 |
D35.3 |
D44.3 |
D44.4 |
D49.7 |
E05.00 |
E05.01 |
E05.10 |
E05.11 |
E05.20 |
E05.21 |
E05.30 |
E05.31 |
E05.40 |
E05.41 |
E05.80 |
E05.81 |
E05.90 |
E05.91 |
E21.0 |
E21.1 |
E21.2 |
E21.3 |
E24.0 |
E24.2 |
E24.3 |
E24.4 |
E24.8 |
E24.9 |
E28.310 |
E28.319 |
E28.39 |
E29.1 |
E74.20 |
E74.21 |
E74.29 |
E89.40 |
E89.41 |
E89.5 |
F50.00 |
F50.01 |
F50.02 |
F50.2 |
F50.81 |
F50.82 |
F50.89 |
G40.001 |
G40.009 |
G40.011 |
G40.019 |
K50.00 |
K50.011 |
K50.012 |
K50.013 |
K50.014 |
K50.018 |
K50.019 |
K50.10 |
K50.111 |
K50.112 |
K50.113 |
K50.114 |
K50.118 |
K50.119 |
K50.90 |
K50.911 |
K50.912 |
K50.913 |
K50.914 |
K50.918 |
K50.919 |
K90.0 |
K90.49 |
K90.89 |
K90.9 |
M48.50XA |
M48.51XA |
M48.52XA |
M48.53XA |
M48.54XA |
M48.55XA |
M48.56XA |
M48.57XA |
M48.58XA |
M80.00XA |
M80.00XD |
M80.0AXA |
M80.0AXD |
M80.0AXG |
M80.0AXK |
M80.0AXP |
M80.0AXS |
M80.0B1A |
M80.0B1D |
M80.0B1G |
M80.0B1K |
M80.0B1P |
M80.0B1S |
M80.0B2A |
M80,0B2D |
M80.0B2G |
M80.0B2K |
M80.0B2P |
M80.0B2S |
M80.0B9A |
M80.0B9D |
M80.0B9G |
M80.0B9K |
M80.0B9P |
M80.0B9S |
M80.8B1A |
M80.8B1D |
M80.8B1G |
M80.8B1K |
M80.8B1P |
M80.8B1S |
M80.8B2A |
M80.8B2D |
M80.8B2G |
M80.8B2K |
M80.8B2P |
M80.8B2S |
M80.8B9A |
M80.8B9D |
M80.8B9G |
M80.8B9K |
M80.8B9P |
M80.8B9S |
M80.011A |
M80.011D |
M80.011G |
M80.011K |
M800B1P |
M80.011P |
M80.011S |
M80.012A |
M80.012D |
M80.012G |
M80.012K |
M80.012P |
M80.012S |
M80.021A |
M80.021D |
M80.021G |
M80.021K |
M80.021P |
M80.021S |
M80.022A |
M80.022D |
M80.022G |
M80.022K |
M80.022P |
M80.022S |
M80.031A |
M80.031D |
M80.031G |
M80.031K |
M80.031P |
M80.031S |
M80.032A |
M80.032D |
M80.032G |
M80.032K |
M80.032P |
M80.032S |
M80.039A |
M80.041A |
M80.041D |
M80.041G |
M80.041K |
M80.041P |
M80.041S |
M80.042A |
M80.042D |
M80.042G |
M80.042K |
M80.042P |
M80.042S |
M80.051A |
M80.051D |
M80.051G |
M80.051K |
M80.051P |
M80.051S |
M80.052A |
M80.052D |
M80.052G |
M80.052K |
M80.052P |
M80.052S |
M80.059A |
M80.059D |
M80.061A |
M80.061D |
M80.061G |
M80.061K |
M80.061P |
M80.061S |
M80.062A |
M80.062D |
M80.062G |
M80.062K |
M80.062P |
M80.062S |
M80.069A |
M80.071A |
M80.071D |
M80.071G |
M80.071K |
M80.071P |
M80.071S |
M80.072A |
M80.072D |
M80.072G |
M80.072K |
M80.072P |
M80.072S |
M80.08XA |
M80.08XD |
M80.08XG |
M80.08XK |
M80.08XP |
M80.08XS |
M80.80XS |
M80.8AXA |
M80.8AXD |
M80.8AXG |
M80.8AXK |
M80.8AXP |
M80.8AXS |
M80.811A |
M80.811D |
M80.811G |
M80.811K |
M80.811P |
M80.811S |
M80.812A |
M80.812D |
M80.812G |
M80.812K |
M80.812P |
M80.812S |
M80.819P |
M80.819S |
M80.821A |
M80.821D |
M80.821G |
M80.821K |
M80.821P |
M80.821S |
M80.822A |
M80.822D |
M80.822G |
M80.822K |
M80.822P |
M80.822S |
M80.831A |
M80.831D |
M80.831G |
M80.831K |
M80.831P |
M80.831S |
M80.832A |
M80.832D |
M80.832G |
M80.832K |
M80.832P |
M80.832S |
M80.839A |
M80.841A |
M80.841D |
M80.841G |
M80.841K |
M80.841P |
M80.841S |
M80.842A |
M80.842D |
M80.842G |
M80.842K |
M80.842P |
M80.842S |
M80.851A |
M80.851D |
M80.851G |
M80.851K |
M80.851P |
M80.851S |
M80.852A |
M80.852D |
M80.852G |
M80.852K |
M80.852P |
M80.852S |
M80.859A |
M80.859G |
M80.861A |
M80.861D |
M80.861G |
M80.861K |
M80.861P |
M80.861S |
M80.862A |
M80.862D |
M80.862G |
M80.862K |
M80.862P |
M80.862S |
M80.871A |
M80.871D |
M80.871G |
M80.871K |
M80.871P |
M80.871S |
M80.872A |
M80.872D |
M80.872G |
M80.872K |
M80.872P |
M80.872S |
M80.88XA |
M81.0 |
M81.6 |
M81.8 |
M84.431A |
M84.432A |
M84.433A |
M84.434A |
M84.439A |
M84.451A |
M84.452A |
M84.459A |
M84.48XA |
M84.531A |
M84.532A |
M84.533A |
M84.534A |
M84.539A |
M84.551A |
M84.552A |
M84.553A |
M84.559A |
M84.58XA |
M84.631A |
M84.632A |
M84.633A |
M84.634A |
M84.639A |
M84.651A |
M84.652A |
M84.653A |
M84.659A |
M84.68XA |
M85.831 |
M85.832 |
M85.841 |
M85.842 |
M85.851 |
M85.852 |
M85.859 |
M85.861 |
M85.862 |
M85.869 |
M85.871 |
M85.872 |
M85.879 |
M85.88 |
M85.89 |
M85.9 |
M89.9 |
M94.9 |
Q78.0 |
R29.890 |
R93.6 |
R93.7 |
Z78.0 |
Z79.51 |
Z79.52 |
Z79.811 |
Z79.818 |
Z79.890 |
Z79.899 |
Z92.21 |
Z92.240 |
Z92.241 |
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Payment for an Additional Bone Density Study Within the One (1) Every Two (2) Years Frequency Limitation for the Following Diagnosis Codes:
Covered Diagnosis Codes for Procedure Codes: 77078, 77080, and 77081
E21.0 |
E21.1 |
E21.2 |
E21.3 |
Z68.35 |
Z68.36 |
Z68.37 |
Z68.38 |
Z68.39 |
Z68.41 |
Z68.42 |
Z68.43 |
Z68.44 |
Z68.45 |
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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.