Bone Mineral Density Studies

Medical Policy: 06.01.21 
Original Effective Date: October 2006 
Reviewed: September 2011 
Revised: February 2009 

Benefit Application
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.

Description: 

Osteoporosis, defined as low bone mass leading to an increased risk of fragility fractures, is an extremely common disease in the elderly due to age-related bone loss in both sexes and menopause-related bone loss in women.

BMD is one of the key determinants for the need for pharmacologic therapy. BMD is typically expressed in terms of the number of standard deviations (SD) the BMD falls below the mean for young healthy adults. This number is termed the T score. The NOF guidelines recommend that pharmacologic therapy be initiated in women with BMD T scores below –2 in the absence of other risk factors, and in women with BMD T scores below –1.5 if other risk factors are present. While BMD measurements are typically used to determine the need for pharmacologic therapy, serial monitoring of BMD to determine treatment response is also commonly performed.

Bone mineral density can be measured with a variety of techniques in a variety of sites. Sites are broadly subdivided into central sites (i.e., hip or spine) and peripheral (i.e., wrist, finger, heel). Dual x-ray absorptiometry (DEXA) is probably the most commonly used method for BMD measurements. Quantitative computed tomography (QCT) may also be used, although it is not as readily available, and has the disadvantages of higher radiation exposure and higher cost. Single and dual photon absorptiometry and radiographic absorptiometry are now rarely used. In particular dual photon absorptiometry may be considered obsolete.

In January 2011, the U.S. Preventive Services Task Force (USPSTF) issued updated recommendations on screening for osteoporosis with bone density measurements. The USPSTF recommends routine osteoporosis screening in women age 65 years or older and in younger women whose risk of fracture is at least equal to that of a 65-year old average-risk white woman. This represents a change from the previous (2002) version in which there was no specific recommendation regarding screening in women younger than 65 years old. The supporting document notes that there are multiple instruments to predict risk for low BMD and that the USPSTF used the FRAX tool. The updated USPSTF recommendations state that the scientific evidence is insufficient to recommend for or against routine osteoporosis screening in men. The Task force did not recommend specific screening tests but said that the most commonly used tests are DXA of the hip and lumbar spine and quantitative ultrasound of the calcaneus. The recommendations state the following in screening intervals,”….A lack of evidence exists about the optimal intervals for repeat screening and whether repeated screening is necessary in women with normal BMD. Because of limitations in the precision of testing, a minimum of two years may be needed to reliably measure a change in BMD; however, longer intervals may be necessary to improve fracture risk prediction.”

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Prior Approval: 

Not applicable

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Policy: 

Screening for osteoporosis with measurement of BMD may be considered medically necessary once every two years to assess fracture risk and the need for pharmacologic therapy in those considered at risk for osteoporosis.

Serial testing may be considered medically necessary every two to three years to assess response and efficacy of pharmacologic therapy.

Repeat testing may be considered medically necessary every three to five years in patients who have previously tested normal.

Testing more frequently than every two years may be considered medically necessary in the following situations:

• Patients on long-term glucocorticoid therapy equal to 5 mg of prednisone or greater, for more than three months
• Male patients with prostate cancer undergoing hormonal manipulation
• To evaluate the effectiveness of a second drug when therapy has been changed based on the results of a previous serial test

The use of ultrasound to measure BMD is considered investigational for all applications.

There is evidence that bone mineral density measurements predict fracture risk and may be useful for individuals at increased risk of fracture who are considering pharmacologic therapy. The greatest amount of support is for central BMD measurements using DXA. There is less evidence on serial or repeat measurement of BMD. The available evidence and the consensus of clinical opinion support at least a 2-year interval in BMD measurement to monitor response to treatment. In addition, the available evidence suggests that a 3- to 5-year timeframe is reasonable for repeat measurement of BMD in individuals who initially tested normal.

Ultrasound densitometry has been investigated as an office based technology for measurement of bone mineral density.  However, research has not shown conclusively that ultrasound measurements of the heel, phalanges or any other sites can be used to accurately predict response to pharmacologic therapy.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.

• 77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)

• 77079 Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)

• 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)

• 77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)

• 77082 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment

• 77083 Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), 1 or more sites

• 76977 Ultrasound bone density measurement and interpretation, peripheral site

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Selected References: 

• National Osteoporosis Foundation. Osteoporosis: Review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Osteoporosis Int 1998; 8(suppl 4):1-88.
• Cummings SR, Palermo L, et al.  Monitoring osteoporosis therapy with bone densitometry: misleading changes and regression to the mean. Fracture Intervention Trial Research Group. JAMA 2000; 283(10):1318-21.
• National Guideline Clearinghouse.  Physician’s Guide to Prevention and Treatment of Osteoporosis. National Osteoporosis Foundation, 1150 17th Street, NW, Suite 500, Washington, DC. (The guide also may be accessed via the Internet at www.nof.org.)
• Krestan C; Grampp S, et al.  Limited diagnostic agreement of quantitative sonography of the radius and phalanges with dual-energy x-ray absorptiometry of the spine, femur, and radius for diagnosis of osteoporosis.  AJR Am J Roentgenol 2004 Sep;183(3):639-44.
• National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis, 2008. Available at: http://www.nof.org/professionals/NOF_Clinicianns_Guideline.pdf. Last viewed February 2009.
• National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis, 2010; Available at: http://www.nof.org/professionals/pdfs/NOF_ClinicianGuide2009_v7.pdf.  Last viewed September 2011.
• Nelson H; Haney E, et al.  Screening for Osteoporosis: An Update for the U.S. Preventative Services Task Force.  Annals of Internal Medicine 2010 July; 153(2):1-13.
• U.S. Preventive Services Task Force (USPSTF). Screening for osteoporosis: recommendations statement. Available online at: http://ahrq.gov/clinic3rduspstf/osteoporosis/osteorr.ht. Last accessed September 2011.
• Bradford J, Richmond JB, Dalinka MK et al. Expert Panel on Musculoskeletal Imaging. American College of radiology. ACR Appropriateness Criteria™: Osteoporosis and bone mineral density. Last review date: 2007. Available online at: http://acsearch.acr.org/variantist.aspx?page=Topics&vid=3018781&topicid=30540. Last accessed September 2011.  

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Policy History: 

Date                                        Reason                               Action

September 2010                     Annual review                    Policy renewed

September 2011                     Annual review                    Policy renewed

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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 © 2010 American Medical Association. All Rights Reserved.