Bone (Mineral) Density Studies

Bone (Mineral) Density Studies Policy Number: Original Effective Date: MM.05.002 03/23/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 03/01/2014 Section: Radiology Place(s) of Service: Outpatient I. Description A bone mineral density (BMD) study is a non-invasive technique that is used to measure bone mineral content and bone mineral density. Its primary role is to detect osteoporosis and to predict the risk of s. Osteoporosis is a disease that results in the loss of bone mineral content or bone density. This leads to thinning and weakening of bones, increasing the risk of s. BMD can be measured with a variety of techniques in a variety of sites that are subdivided into central (hip or spine) and peripheral (wrist, finger or heel). Dual x-ray absorptiometry (DXA) is the most commonly used technique for BMD measurements. Quantitative computed tomography (QCT) may also be used, although it is not as readily available, and has the disadvantage of higher radiation exposure. Ultrasound (US) densitometry is as an office based technology for measuring BMD at peripheral sites, mainly the heel. Peripheral measurements can identify patients with low bone mass, but cannot predict response to pharmacologic therapy and is not a substitute for central BMD measurements. Therefore, central BMD measurements are recommended for the initial diagnosis and for repeat BMD measurements. II. Criteria/Guidelines A. An initial BMD study of the hip and/or spine is covered (subject to Limitations/Exclusions and Administrative Guidelines) to assess risk and the need for pharmacologic therapy in the following individuals considered to be at high-risk for osteoporosis: 1. Women 65 years of age or older and men 70 years of age or older 2. Postmenopausal women with any of the following risk factors: a. History of a low-impact * after age 45 in a first-degree relative b. Body weight of less than 127 lbs. or BMI of 20 or less c. Current smoker d. Surgical or natural menopause before age 40

Bone Mineral Density Studies 2 3. Premenopausal women with documented hypo-estrogenic amenorrhea for more than one year 4. Men or women with the following chronic conditions known to be associated with bone loss: a. Cushing's syndrome b. Male hypogonadism for more than five years c. Hyperthyroidism d. Hyperparathyroidism e. Ankylosing spondylitis f. Rheumatoid arthritis g. Systemic lupus erythematosus h. Leukemia i. Multiple myeloma j. Chronic kidney disease (stages III, IV and V) k. Celiac disease l. Prolonged severe loss of mobility (unable to ambulate outside of one's dwelling without a wheelchair for more than one year) 5. Patients taking any of the following medications associated with bone loss: a. Anticonvulsants b. Oral glucocorticoids for more than three months at a dose equivalent to 5 mg of prednisone or greater per day c. Aromatase inhibitors d. Chemotherapy agents (i.e., methotrexate or other antimetabolites) e. Depo-medroxy progesterone acetate (Depo-Provera) when used for more than two years f. Gonadotropin-releasing hormone (GnRH) agonists (buserelin, leuprolide, nafarelin) 6. Solid organ or allogeneic bone marrow transplant recipients 7. Patients with osseous abnormalities shown on imaging studies indicative of osteoporosis, osteopenia or a vertebral compression (defined as vertebral body height loss of 30% or more) 8. Adults who have had a documented low-impact (excluding fingers and toes) within the past two years 9. Children with a disease or condition associated with bone loss or on prolonged medications that are known to decrease bone mass B. Peripheral BMD studies are covered (subject to Limitations/Exclusions and Administrative Guidelines) if the hip/spine cannot be done or the patient is over the table limit for weight A low-impact is defined as a occurring spontaneously or from a fall from standing height, including s from activities such as a cough, sneeze or abrupt movement (e.g., opening a window)

Bone Mineral Density Studies 3 III. Limitations/Exclusions A. Routine BMD screening for osteoporosis is not recommended for women under the age of 65 and for men under the age of 70 B. Repeat central BMD studies are limited to one every two years (23 months must past since the previous BMD study) for patients whose last scan showed osteopenia/osteoporosis C. Repeat central BMD studies for individuals who previously tested normal may be retested no sooner than three years from the last BMD if they continue to meet the criteria listed above D. Repeat central BMD studies performed more frequently than once every two years are limited to individuals currently taking an aromatase inhibitor or on glucocorticoid therapy equivalent to 5.0 mg or more of prednisone per day for more than three months E. A follow up DXA is not covered when used to confirm a diagnosis obtained by an US or QCT F. Clinicians are encouraged to use the same facility and same scanner for initial and follow-up BMD studies whenever possible for greater consistency G. Dual Photon Absorptiometry (DPA) and images obtained during a BMD study (e.g., rapid vertebral assessment) are not covered H. 3D reconstruction is not covered for BMD studies IV. Administrative Guidelines A. Precertification is required for the following: 1. Patients under the age of 18. To precertify, please complete HMSA's Precertification Request and mail or fax the form as indicated. The request must include supporting documentation from the patient's medical records with the high-risk indications that would justify a BMD study as well as the proposed therapy for the patient 2. For follow-up studies performed more frequently than once every two years. Requests must include the previous BMD study results, other pertinent test findings and a list of medications the patient is currently taking B. Compliance with the provisions in this policy is subject to monitoring, post payment data analysis, and subsequent medical review. The following documentation should be kept in the patient's medical records and made available upon request: 1. Clinical indications to substantiate that the test is reasonable and necessary 2. Physician s order signed (not rubber-stamped) and dated (mm/dd/yy) 3. The diagnostic evaluation documenting symptoms, other diagnostic X-rays, and physical exam findings must have been dated at a time reasonably proximate to the scan 4. The name and medication regimen for patients undergoing drug therapy C. If a patient does not meet HMSA s guidelines for coverage but has indicated that he or she wants the services performed despite noncoverage, the patient should be asked to sign HMSA's Agreement of Financial Responsibility. A signed waiver indicates that the patient will be responsible for the denied charges D. When submitting a claim for a BMD study that does not meet HMSA guidelines, append modifier code GA to the CPT code for the service. The use of the GA modifier will alert HMSA

Bone Mineral Density Studies 4 that the claim should be processed to indicate that the patient will be financially responsible for the service, and that the noncovered charges should not be a provider adjustment E. The signed waiver should be kept in the patient's record. HMSA reserves the right to conduct periodic audits on claims submitted with the GA modifier and review medical records for signed waivers for this service F. The following codes are provided for informational purposes only. Inclusion/exclusion of a procedure or diagnosis does not constitute or imply coverage or provider reimbursement: ICD-9 codes Description 252.00-252.08 Hyperparathyroidism (code range) 255.0 Cushing's syndrome 256.2 Post ablative ovarian failure 256.31 Premature menopause 256.39 Other ovarian failure 345.00-345.91 Epilepsy (code range) 579.0 Celiac disease 585.3 Chronic kidney disease, Stage III (moderate) 585.4 Stage IV (severe) 585.5 Stage V 588.81 Secondary hyperparathyroidism (of renal origin) 626.0 Absence of menstruation 627.2-627.9 Menopausal and postmenopausal disorders 710.0 Systemic lupus erythematosus 714.0 Rheumatoid arthritis 720.0 Ankylosing Spondylitis 733.00-733.09 Osteoporosis (Code range) 733.10 Pathological, unspecified 733.11 Pathological, humerus 733.12 Pathologic of distal radius and ulna 733.90 Disorders of bone and cartilage unspecified E932.0 Adrenal cortical steroids causing adverse effects in therapeutic use (cortisone derivatives, desoxycorticosterone derivatives, fluorinated corticosteroids). E932.2 Ovarian hormones and synthetic substitutes. To be used with ICD-9-CM V58.69 for reporting an individual receiving long term Depo Provera

Bone Mineral Density Studies 5 injections. V49.81 Asymptomatic postmenopausal status (age-related, natural) V58.65 Long term (current) use of steroids V58.69 Long-term (current) use of other medications (includes high-risk medications) V67.51 Following completed treatment with high-risk medication, not elsewhere classified. To be used for reporting an individual who has completed drug therapy for osteoporosis and is being monitored for response to therapy. V67.59 Following other treatment. To be used for reporting an individual who is receiving ongoing drug therapy for osteoporosis and is being monitored for effectiveness. V82.81 Special screening for other conditions, osteoporosis Applicable CPT codes: CPT Code Description 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method 77078 Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) 77080 Dual energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) 77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Codes that do not meet payment determination criteria: CPT code Description 77082 Vertebral assessment 78350 Bone density (bone mineral content) study, one or more sites; single photon absorptiometry 78351 Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites HCPCS Code G0130 Description Single energy X-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Bone Mineral Density Studies 6 ICD-10 codes are provided for your information. These will not become effective until 10/1/2014: ICD-10 Description E21.0 Primary hyperparathyroidism E21.1 Secondary hyperparathyroidism, not elsewhere classified E21.2 Other hyperparathyroidism E21.3 Hyperparathyroidism unspecified E28.310 Symptomatic premature menopause E28.319 Asymptomatic premature menopause E28.39 Other primary ovarian failure E89.40 Asymptomatic postprocedure ovarian failure E89.41 Symptomatic postprocedural ovarian failure G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status G40.009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status

Bone Mineral Density Studies 7 G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status G40.501 Special epileptic syndromes, not intractable, with status G40.509 Special epileptic syndromes, not intractable, without status G40.801 Other epilepsy, not intractable, with status G40.802 Other epilepsy, not intractable, without status G40.803 Other epilepsy, intractable, with status G40.804 Other epilepsy, intractable, without status G40.89 Other seizures G40.901 Epilepsy, unspecified, not intractable, with status G40.909 Epilepsy, unspecified, not intractable, without status G40.911 Epilepsy, unspecified, intractable, with status

Bone Mineral Density Studies 8 G40.919 Epilepsy, unspecified, intractable, without status K90.0 Celiac disease M05.70 Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or M05.711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or M05.712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or M05.719 Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or M05.721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or M05.722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or M05.729 Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or M05.731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or M05.732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or M05.739 Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or M05.741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or M05.742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or M05.749 Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or M05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or M05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or M05.759 Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or

Bone Mineral Density Studies 9 M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or M05.769 Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or M05.779 Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or M05.811 Other rheumatoid arthritis with rheumatoid factor of right shoulder M05.812 Other rheumatoid arthritis with rheumatoid factor of left shoulder M05.821 Other rheumatoid arthritis with rheumatoid factor of right elbow M05.822 Other rheumatoid arthritis with rheumatoid factor of left elbow M05.831 Other rheumatoid arthritis with rheumatoid factor of right wrist M05.832 Other rheumatoid arthritis with rheumatoid factor of left wrist M05.841 Other rheumatoid arthritis with rheumatoid factor of right hand M05.842 Other rheumatoid arthritis with rheumatoid factor of left hand M05.851 Other rheumatoid arthritis with rheumatoid factor of right hip M05.852 Other rheumatoid arthritis with rheumatoid factor of left hip M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee M05.871 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot M05.872 Other rheumatoid arthritis with rheumatoid factor of left ankle and foot M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified M06.011 Rheumatoid arthritis without rheumatoid factor, right shoulder M06.012 Rheumatoid arthritis without rheumatoid factor, left shoulder M06.021 Rheumatoid arthritis without rheumatoid factor, right elbow M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow M06.031 Rheumatoid arthritis without rheumatoid factor, right wrist

Bone Mineral Density Studies 10 M06.032 Rheumatoid arthritis without rheumatoid factor, left wrist M06.041 Rheumatoid arthritis without rheumatoid factor, right hand M06.042 Rheumatoid arthritis without rheumatoid factor, left hand M06.051 Rheumatoid arthritis without rheumatoid factor, right hip M06.052 Rheumatoid arthritis without rheumatoid factor, left hip M06.061 Rheumatoid arthritis without rheumatoid factor, right knee M06.062 Rheumatoid arthritis without rheumatoid factor, left knee M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and foot M06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and foot M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites M06.9 Rheumatoid arthritis, unspecified M32.0 Drug-induced systemic lupus erythematosus M32.10 Systemic lupus erythematosus, organ or system involvement unspecified M32.11 Endocarditis in systemic lupus erythematosus M32.12 Pericarditis in systemic lupus erythematosus M32.13 Lung involvement in systemic lupus erythematosus M32.14 Glomerular disease in systemic lupus erythematosus M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus M80.021A M80.022A M80.029A M80.031A M80.032A M80.039A M80.80xA Age-related osteoporosis with current pathological, right humerus, initial encounter for Age-related osteoporosis with current pathological, left humerus, initial encounter for Age-related osteoporosis with current pathological, unspecified humerus, initial encounter for Age-related osteoporosis with current pathological, right forearm, initial encounter for Age-related osteoporosis with current pathological, left forearm, initial encounter for Age-related osteoporosis with current pathological, unspecified forearm, initial encounter for Other osteoporosis with current pathological, unspecified site, initial encounter for

Bone Mineral Density Studies 11 M80.821A M80.822A M80.829A M80.831A M80.832A M80.839A Other osteoporosis with current pathological, right humerus, initial encounter for Other osteoporosis with current pathological, left humerus, initial encounter for Other osteoporosis with current pathological, unspecified humerus, initial encounter for Other osteoporosis with current pathological, right forearm, initial encounter for Other osteoporosis with current pathological, left forearm, initial encounter for Other osteoporosis with current pathological, unspecified forearm, initial encounter for M81.0 Age-related osteoporosis without current pathological M81.6 Localized osteoporosis M81.8 Other osteoporosis without current pathological M84.40xA M84.421A M84.422A M84.429A M84.431A M84.432A M84.433A M84.434A M84.439A M84.50xA M84.521A M84.522A M84.529A M84.531A Pathological, unspecified site, initial encounter for Pathological, right humerus, initial encounter for Pathological, left humerus, initial encounter for Pathological, unspecified humerus, initial encounter for Pathological, right ulna, initial encounter for Pathological, left ulna, initial encounter for Pathological, right radius, initial encounter for Pathological, left radius, initial encounter for Pathological, unspecified ulna and radius, initial encounter for Pathological in neoplastic disease, unspecified site, initial encounter for Pathological in neoplastic disease, right humerus, initial encounter for Pathological in neoplastic disease, left humerus, initial encounter for Pathological in neoplastic disease, unspecified humerus, initial encounter for Pathological in neoplastic disease, right ulna, initial encounter for

Bone Mineral Density Studies 12 M84.532A M84.533A M84.534A M84.539A M84.60xA M84.621A M84.622A M84.629A M84.631A M84.632A M84.633A M84.634A M84.639A Pathological in neoplastic disease, left ulna, initial encounter for Pathological in neoplastic disease, right radius, initial encounter for Pathological in neoplastic disease, left radius, initial encounter for Pathological in neoplastic disease, unspecified ulna and radius, initial encounter for Pathological in other disease, unspecified site, initial encounter for Pathological in other disease, right humerus, initial encounter for Pathological in other disease, left humerus, initial encounter for Pathological in other disease, unspecified humerus, initial encounter for Pathological in other disease, right ulna, initial encounter for Pathological in other disease, left ulna, initial encounter for Pathological in other disease, right radius, initial encounter for Pathological in other disease, left radius, initial encounter for Pathological in other disease, unspecified ulna and radius, initial encounter for N18.3 Chronic kidney disease, stage 3 (moderate) N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N25.81 Secondary hyperparathyroidism of renal origin N91.0 Primary amenorrhea N91.1 Secondary amenorrhea N91.2 Amenorrhea, unspecified N95.1 Menopausal and female climacteric states N91.2 Amenorrhea, unspecified Z78.0 Asymptomatic menopausal state

Bone Mineral Density Studies 13 Z79.3 Long term (current) use of hormonal contraceptives Z79.52 Long term (current) use of systemic steroids Z79.899 Other long term (current) drug therapy VI. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii's Patients' Bill of Rights and Responsibilities Act (Hawaii Revised Statutes 432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA's determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation. VI. References 1. Watts NB, Bilezikian JP, Camacho PM, Greenspan SL, Harris ST, Hodgson SF, Kleerekoper M, Luckey MM, McClung MR, Pollack RP, Petak SM, AACE Osteoporosis Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis. Endocr Pract. 2010 Nov-Dec; 16(Suppl 3):1-37. 2. BCBSA Medical Policy Reference Manual. Bone density studies. Policy #6.01.01. Last review March 2013 3. Diagnosis of Osteoporosis in Men, Premenopausal Women, and Children. J Clin Densitom 2004 Spring; 7(1):17-26. [82 references] 4. Hau Liu, Neil M. Paige, et.al: Screening for osteoporosis in men: A systematic review from the American College of Physicians Guideline. Ann Intern Med, May 2008; 148: 685-701. 5. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline, Diagnosis and Treatment of Osteoporosis. Eighth Edition July 2013 6. National Osteoporosis Foundation: Clinicians Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013. 7. U.S. Preventive Services Task Force. Screening for Osteoporosis. Recommendation Statement. January 2011. Agency for Healthcare Research and Quality, Rockville, MD.

Bone Mineral Density Studies 14 8. Ward L, et al; Bisphosphonate Therapy for Children and Adolescents with Secondary Osteoporosis. Premedline identifier 17943849. Cochrane database sys rev. 2007. 9. Conference of Radiation Control Program Directors' Task Force on Bone Densitometry. Technical white paper: Bone Densitometry. October 2006. 10. World Health Organization Collaborating Centre for Metabolic Bone Diseases. WHO Fracture Risk Assessment tool. Available online at http://www.shef.ac.uk/frax/tool.jsp