BlueCross BlueShield of Tennessee Medical Policy Manual

Bone Mineral Density Studies

DESCRIPTION

Bone densitometry is a non-invasive technique used to measure bone mineral density (BMD), in order to predict fracture risks. The following technologies are most commonly used:

Osteoporosis is a disease that results in the loss of bone mineral content or bone density. This leads to thinning and weakening of bones and problems such as increase risk of fracture and pain. Individuals with osteopenia have sustained some bone loss and may be at risk for further loss. Primary osteoporosis is usually related to age deficient calcium intake, early menopause, smoking, sedentary life-style without adequate exercise, and a familial history of the disease. Disease or other factors such as drugs or some nutritional conditions that affect the body and cause bone loss cause secondary osteoporosis.

POLICY

Bone mineral density studies, using DEXA, DPA, QCT or SPA when osteoporosis is suspected, are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Bone mineral density studies, to monitor secondary osteoporosis, are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Follow-up bone mineral density studies, to determine the efficacy of treatment and to monitor the progression of osteoporosis, are considered medically necessary. (See Medical appropriateness below.)

Bone mineral density studies, for screening of osteoporosis or osteoporosis risks when osteoporosis is not suspected, are considered not medically necessary.

Ultrasound densitometry for diagnosing osteoporosis is considered investigational.

MEDICAL APPROPRIATENESS

Bone mineral density studies, whenever a clinical decision will be influenced by the outcome of the test, are considered medically appropriate for an individual (male or female) with any of the following:

Bone mineral density studies to monitor secondary osteoporosis are considered medically appropriate for an individual with any of the following conditions:

ADDITIONAL INFORMATION

Accepted in accordance with the 1996 Tennessee State Mandate.

If an individual has one or more low trauma fractures, he/she should be considered to have osteoporosis regardless of the bone mineral density (BMD) value.

Ultrasound densitometry for diagnosing osteoporosis does not meet the following technology evaluation criteria:

SOURCES

American Association of Clinical Endocrinologist (AACE). (2003, November/December). AACE medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Retrieved March 6, 2006 from http://www.aace.com/pub/pdf/guidelines/osteoporosis2001Revised.pdf

American College of Radiology (ACR). (2001). ACR appropriateness criteria™: Osteoporosis and bone mineral density. Retrieved March 7, 2006 from http://www.acr.org/s_acr/bin.asp?TrackID=&SID=1&DID=11796&CID=1206&VID=2&DOC=File.PDF.

BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2005). Bone mineral density studies. (6.01.01). Retrieved February 27, 2006 from BlueWeb.

Code of Federal Regulations. 42CFR410.31. (2002, October). Bone mass measurement: Conditions for coverage and frequency standards. Retrieved April 14, 2003 from http://frwebgate5.access.gpo.gov/cgi-bin/waisgate.cgi?WAISdocID=33260722756+4+0+0&WAISaction=retrieve.

Complete Guide to Medicare Coverage Issues [Computer software]. (2005, November). Bone (mineral) density studies, (NCD 150.3, pp. 2-62, 2-63). St. Anthony Publishing.

Food and Drug Administration. (1987, March). Center for Devices and Radiological Health. Pre-Market approval decisions for March 1987. Retrieved April 14, 2003 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?ID=44291.

Gallagher, J. C., Ettinger, B., Gass, M. L. S., Kagan, R., McClung, B. L., McClung, M. R., et al. (2002). Position statement: Management of postmenopausal osteoporosis: position statement of The North American Menopause Society. Menopause: The Journal of the North American Menopause Society, 9 (92), 84-101.

Health Technology Advisory Committee (1997, August). Bone densitometry as a screening tool for osteoporosis in postmenopausal women. Retrieved April 14, 2003 from http://www.health.state.mn.us/htac/bone.htm.

Health Technology Assessment Information Service. Executive Briefing. (1995, December). Bone density screening for osteoporosis. Retrieved April 11, 2003 from ECRI HTAIS.

Health Technology Assessment Information Service. Executive briefings. (1998, May). Osteoporosis: an overview of current prevention, diagnostic, and treatment methods. Retrieved April 11, 2003 from ECRI HTAIS.

Health Technology Assessment Information Service. Windows on Medical Technology™. (2000, February). Ultrasound bone densitometry for diagnosis of osteoporosis. Retrieved April 11, 2003 from ECRI HTAIS.

Institute for Clinical Systems Improvement. (2000, January). Densitometry as a diagnostic tool for the identification and treatment of osteoporosis in women. Retrieved April 14, 2003 from http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=277.

Institute for Clinical Systems Improvement. (2005, September). Diagnosis and treatment of osteoporosis. Retrieved March 8, 2006 from http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=547.

National Institutes of Health (NIH) Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. (2001). Osteoporosis prevention, diagnosis, and therapy. JAMA, 283 (6), 785-795.

National Osteoporosis Foundation. (1999). Physician's guide to prevention and treatment of osteoporosis. 1-29. Belle Mead, NJ, Excerpta Medica, Inc.

Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 25 Mandated Insurer or Plan Options: 56-7-2506. Bone mass measurement coverage - Osteoporosis.

The Technology Evaluation Center [Computer software]. (2000, February). Monitoring of bone density to access active treatment of osteoporosis (Vol. 14, No. 24). Chicago: BlueCross BlueShield Association.

The Technology Evaluation Center [Computer software]. (2002, July). Ultrasonography of peripheral sites for selecting patients for pharmacologic treatment for osteoporosis (Vol. 17, No. 5). Chicago: BlueCross BlueShield Association.

U.S. Preventive Services Task Force. (2002, September). Screening for Osteoporosis in Postmenopausal Women. Annals of Internal Medicine, 137, 526-528. Retrieved August 7, 2003 from http://www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm.

EFFECTIVE DATE

4/13/2006

 

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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