Collagen Cross-Link Testing for Management of Osteoporosis Printer-Friendly Version   

Medical Policy: 02.04.13 
Original Effective Date: October 2007 
Reviewed: October 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: 

After cessation of growth, bone is in a constant state of remodeling or turnover, with initial absorption of bone by osteoclasts followed by deposition of new bone matrix by osteoblasts. This constant bone turnover is critical to the overall health of the bone, by repairing microfractures and remodeling the bony architecture in response to stress. However, it must be emphasized that the presence of bone-turnover markers in the serum or urine is not necessarily related to bone loss. For example, even if bone turnover is high, if resorption is balanced with formation, there will be no net bone loss. Bone loss will only occur if resorption exceeds formation.

Bone-turnover markers have been extensively researched in diseases associated with markedly high levels of bone turnover, such as Paget’s disease, primary hyperparathyroidism, glucocorticoid-induced osteoporosis, or renal osteodystrophy. There has been recent interest in the use of bone-turnover markers to evaluate age-related osteoporosis, a disease characterized by slow, prolonged bone loss, resulting in an increased risk of fractures at the hip, spine, or wrist.

Currently, fracture risk is based primarily on measurements of bone mineral density (BMD) in conjunction with other genetic and environmental factors, such as family history of osteoporosis, history of smoking, and weight.

It is not clear how collagen cross link results may be used in the clinical management of patients with osteoporosis or other disorders. This is because all patients with osteoporosis, as identified by measurement of BMD, would be considered candidates for drug therapy, typically the use of hormone replacement therapy, bisphosphonates, or calcitonin. It is not clear how therapy should be adjusted according to the level of fracture risk or whether the use of bone-turnover markers can predict response to therapy. Studies have shown that bone-turnover markers are only weakly correlated to magnitude of treatment response, a finding that does not support a role in treatment planning.

Policy: 

Collagen cross link measurements of bone turnover are considered investigational in the diagnosis and management of osteoporosis or other conditions associated with increased bone turnover.

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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.
• CPT 82523 collagen cross links, any method

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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.
• National Osteoporosis Foundation. Physician’s guide to prevention and treatment of osteoporosis. April 2003.
• Stepan JJ.  Clinical utility of bone markers in the evaluation and follow-up of osteoporotic patients: why are the markers poorly accepted by clinicians?  J Endocrinol Invest. 2003 May;26(5):458-63.
• Meunier PJ, Roux C, et al. The effects of strontium ranelate on the risk of vertebral fracture in women with postmenopausal osteoporosis.  N Engl J Med. 2004 Jan 29;350(5):459-68.
• Paschalis EP, Glass EV,et al.  Bone mineral and collagen quality in iliac crest biopsies of patients given teriparatide: new results from the fracture prevention trial.  J Clin Endocrinol Metab. 2005 Aug;90(8):4644-9.
• Bauer DC, Garnero P, et al.  Pretreatment levels of bone turnover and the antifracture efficacy of alendronate: the fracture intervention trial.  J Bone Miner Res. 2006 Feb;21(2):292-9.
• Black DM, Schwartz AV,et al.   Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 2006 Dec 27;296(24):2927-38.
•  Deane A, Constancio L, et al. The impact of vitamin D status on changes in bone mineral density during treatment with bisphosphonates and after discontinuation following long-term use in post-menopausal osteoporosis.  BMC Musculoskelet Disord. 2007 Jan 10;8:3.

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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.

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