HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
X-24-057
Topic:
Bone Mineral Density Studies
Section:
Radiology
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
September 2022
 
 

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.

Policy Position

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:

  • To allow simultaneous axial (spine, hips, pelvis) and peripheral (forearm, radius, wrist) bone density testing for hyperparathyroidism; or
  • To allow peripheral (forearm, radius, wrist) bone density testing in lieu of the axial skeleton (spine, hips, pelvis) in the very obese individual (defined as an individual with a BMI of 35 or greater) when the individual's weight exceeds the weight limit for the DXA table; or
  • 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 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:

  • Women age 65 and older; or
  • Men age 70 and older; or
  • Post-menopausal individuals above age 50-69, based of risk factor profile; or
  • Post-menopausal individuals age 50 and older who have had an adult age fracture, to diagnoses and determine degree of osteoporosis; or
  • The individual is on long term steroid therapy three (3) month duration or longer with a dosage of five (5) mg per day of prednisone, or equivalent; or
  • The individual is on long term anticonvulsant therapy (i.e. Phenytoin, Dilantin) three (3) month duration or longer; or
  • To determine if significant osteoporosis is present when associated with vertebral abnormalities on x-ray (i.e. compression fractures) or radiographic evidence of osteopenia; or
  • Fractures of the hip, wrist, or spine in the absence of appropriate severe trauma; or
  • Documented loss of height of 1.5 inches or greater; or
  • To monitor and evaluate response to ongoing restorative treatment (i.e., Fosamax) for individuals with documented osteoporosis; or
  • The individual suffers from one of the following calcium-wasting endocrinopathies:
    • Cushing's Syndrome; or
    • Hyperparathyroidism; or
    • Hyperthyroidism; or
    • Hypogonadism (except for uncomplicated, naturally occurring, or surgically induced post-menopausal clinical cases); or
    • Prolactinoma; or
    • Celiac Sprue; or
  • The individual has prostate cancer with androgen deprivation; or
  • Eating disorders, including anorexia nervosa and bulimia; or
  • Breast cancer patients who are on aromatase inhibitors.

DXA for pediatrics (until age 19) may be considered medically necessary when ANY ONE of the following is met:

  • Prolonged use of glucocorticoid or corticosteroid therapy; or
  • Chronic inflammatory disease; or
  • Hypogonadism; or
  • Idiopathic juvenile osteoporosis; or
  • Long term immobilization; or
  • Osteogenesis imperfecta; or
  • Completion of chemotherapy two (2) years prior to ordering DXA.

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

 

 

 

 




Single Photon Absorptiometry (SPA), Dual-Photon Absorptiometry (DPA), and radiographic absorptiometry (i.e., photodensitometry, radiogrammetry) are considered not medically necessary.

78350

78351

 

 

 

 

 




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

 

 

 

 

 

 

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

 



Place of Service: Outpatient



The policy position applies to all commercial lines of business



Links






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:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

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:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • 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.