Medical Policy: 06.01.31
Original Effective Date: September 2013
Reviewed: August 2014
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Body composition measurement tools measure the presence of water, minerals, protein, and fat in the body. These measurement tools have been proposed as a method to evaluate patients' nutrition, growth and disease. Body composition measurement has been used as a tool in the research setting in studies evaluating normal human growth and development, as well as disease processes and treatments. However, current peer-reviewed, scientific literature does not define what specific role, if any, body composition measurement has in patient management, predicting health risk and whether it improves clinical outcomes. Methods of measuring body composition that have been proposed include:
anthropometry (i.e., measuring skinfold thickness[SKF])
circumference measures, including waist-to-hip ratio (WHR)
bioelectrical impedance analysis (BIA)
air displacement plethysmography (ADP)
computed tomography (CT)
magnetic resonance imaging (MRI)
whole body dual-energy x-ray absorptiometry (DEXA or DXA)
Dual-energy x-ray absorptiometry (DEXA or DXA) scanning was primarily developed for the diagnosis of osteoporosis and was initially applied to clinically important sites of the lumbar spine, femoral neck, and forearm. With whole body DEXA/DXA scanning, a controlled x-ray beam scans the entire body for determination of bone mineral content, body fat and lean tissue mass. The comprehensive view of body composition provided by DEXA/DXA is purported to be the clinical method of choice for assessing body composition by its supporters because of its relatively low dose of ionizing radiation, speed, and ease of application. Its proposed utility includes determining appropriate nutritional support during disease progression and monitoring response to therapeutic interventions.
The use of DEXA/DXA in the evaluation of body composition is becoming more widespread. It can be easily used in clinical studies and in various health care delivery locations. One disadvantage is in regards to follow up. Follow up of a patient requires the use of the same DEXA/DXA scanner and caution is needed when comparing results from different scanners.
There is insufficient evidence to support the use of whole body DXA for the purpose of determining body composition. The current published, peer-reviewed scientific literature does not establish the accuracy of whole body DXA when used to measure body composition and the impact this testing may have on meaningful clinical outcomes has not been demonstrated. Published evidence is primarily in the form of small, heterogeneous studies that focus on the level of agreement or correlation between various methods of body composition measurement. The studies demonstrate whole body DXA is used in a research setting, across a broad range of disease states and normal growth and development. Well-designed studies evaluating the diagnostic accuracy and clinical utility of this testing are lacking. The technique is considered investigational.
Whole body dual x-ray absorptiometry (DEXA or DXA) for body composition testing is considered investigational.
There is insufficient evidence to support the use of whole body DEXA or DXA for the purpose of determining body composition. The current published, peer-reviewed scientific literature does not establish the accuracy of whole body DEXA or DXA when used to measure body composition and the impact this testing may have on meaningful clinical outcomes has not been demonstrated. The technique is considered investigational.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 76499 unlisted diagnostic radiographic procedure
- Methods for Body Composition Analysis in Adults, The Open Obesity Journal, 2011, Volume 3, 62-69
- Centers for Disease Control and Prevention: Healthy Weight: Assessing Your Weight: BMI: About BMI for Adults.
- U.S. Preventative Services Task Force: Screening for and Management of Obesity in Adults.
- U.S. Preventative Services Task Force: Screening for Obesity in Children and Adolescents.
- American Heart Society Body Composition Tests
- International Society for Clinical Densitometry: 2013 ISCD Official Positions-Adult.
- International Society for Clinical Densitometry: 2007 Pediatric Official Positions.
- Agency for Healthcare Research and Quality: Screening and Intervention for Childhood Overweight: Evidence Synthesis. July 2005. Investigators: Evelyn P. Whitlock, M.D., MPH; Selvi B. Williams, M.D.; Rachel Gold, PhD, MPH; Paula Smith, R.N., BSN; Scott Shipman, M.D., MPH
- Evaluation of Lunar Prodigy dual energy x-ray absorptiometry for assessing body composition in healthy persons and patients by comparison with the criterion 4-component model. American Journal of Clinical Nutrition 2006. Jane E. Williams, Jonathan CK Wells, Catherine M. Wilson, Dalia Haroun, Alan Lucas and Mary S. Fewtrell.
- American College of Radiology (ACR) and the Society of Skeletal Radiology (SSR) Practice Guideline for the Performance of Dual Energy X-Ray Absorptiometry (DXA). Revised 2008
- Pediatrics Official Journal of the American Academy of Pediatrics: Prevention of Pediatric Overweight and Obesity Committee on Nutrition, 2003, 112;424
Date Reason Action
September 2013 New policy
August 2014 Annual review Policy renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.