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Medical Policy: 06.01.21
Original Effective Date: October 2006
Reviewed: January 2008
Revised:
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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. Current practice guidelines published by the National Osteoporosis Foundation (NOF) recommend that measurement of bone mineral density (BMD) be performed in all women over age 65 and in postmenopausal women who have additional risk factors. Additional risk factors include a personal history of fracture as an adult, history of fracture in first-degree relative, current cigarette smoking, and low body weight (<127 lbs.). Patients receiving glucocorticoid therapy are also at risk for bone loss, no matter what the age. Therefore, BMD measurements are often performed before initiating therapy.
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.
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.
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 measurements of BMD to monitor treatment response are considered not medically necessary.
The use of ultrasound to measure BMD is considered investigational for all applications.
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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.
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CPT 77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
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CPT 77079 Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)
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CPT 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
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CPT 77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)
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CPT 77082 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment
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CPT 77083 Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), 1 or more sites
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CPT 76977 Ultrasound bone density measurement and interpretation, peripheral site
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross and Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- A review of the medical literature and recommendations from Wellmark’s Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
- 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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