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:
Dual-Energy X-ray Absorptiometry (DEXA): measures bone mineral content and bone mineral density. It is also known as dual-energy radiography (DER), dual-energy radiographic absorptiometry (DRA), quantitative digital radiography (QDR), and dual X-ray absorptiometry (DXA). It is a two-dimensional projection system in which an X-ray tube source, rather than a radioisotope, is used as a photon source, providing for more accurate and precise readings. DEXA is used to measure bone mineral in both the peripheral appendicular skeleton and in axial skeletal sites, including trabecular and cortical bone, (e.g., wrists, hip, spine, or total skeleton).
Quantitative Computed Tomography (QCT): measures bone mineral content at both appendicular and axial skeletal sites.
Ultrasound densitometry measures BMD at peripheral sites, typically the heel. Compared to osteoporotic bone, normal bone demonstrates higher attenuation of the ultrasound wave and is associated with a greater velocity of the wave passing through bone. Ultrasound densitometry has no radiation exposure and machines may be purchased for use in an office setting.
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 (BMD) studies for the diagnosis and management of osteoporosis are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Repeat measure of central (hip/spine) BMD may be medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Regular serial measurements of central BMD to monitor treatment response is considered medically necessary if the medical appropriateness criteria are met. (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 for the diagnosis and management of osteoporosis are considered medically appropriate if ALL of the following criteria are met:
The studies are completed using DEXA
A clinical decision will be influenced by the outcome of the test
The initial measurement of BMD is completed using the hip or spine
ANY ONE of the following individuals:
Women age 65 years and older, regardless of other risk factors .(See Additional Information below for risk factors)
Men age 70 and older, regardless of other risk factors .(See Additional Information below for risk factors)
Younger postmenopausal women about whom there is a concern based on their risk factors .(See Additional Information below for risk factors)
Men age 50-69 about whom there is a concern based on their risk factors .(See Additional Information below for risk factors)
Women in the menopausal transition if there is a specific risk factor associated with increased fracture risk such as low body weight, prior low-trauma fracture or high-risk medication
Adults who have a fracture after age 50
Adults with a condition (e.g., rheumatoid arthritis) or taking medication (e.g., glucocorticoids in a daily dose ≥ 5 mg prednisone or equivalent for ≥ three months) associated with low bone mass or bone loss
Anyone being considered for pharmacologic therapy for osteoporosis
Anyone being treated for osteoporosis, to monitor treatment effect
Anyone with identified risk factors not receiving treatment in whom there is evidence of bone loss that would lead to treatment.(See Additional Information below for risk factors)
Postmenopausal women discontinuing estrogen should be considered for bone density testing
Repeat measure of central (hip/spine) BMD is considered medically appropriate if ALL of the following criteria are met:
The individual previously tested normal (not requiring pharmacologic treatment)
The interval is not more frequent than every 3-5 years, depending on the individual’s risk factors
Regular serial measurements of central BMD to monitor treatment response is considered medically appropriate if ALL of the following criteria are met:
Regular serial measurements are not more frequent than every 2-3 years
The information will affect treatment decisions such as duration of therapy
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.
The World Health Organization (WHO) Fracture Risk Assessment Model (FRAX), in addition to age, gender and bone mineral density; include:
Low body mass index
Parental history of hip fracture
Previous fragility fracture in adult life (i.e., occurring spontaneously, or a fracture arising from trauma which, in a healthy individual, would not have resulted in a fracture)
Current smoking or alcohol 3 or more units/day, where a unit is equivalent to a standard glass of beer (285 mg), a single measure of spirits (30ml), a medium-sized glass of wine (120ml), or 1 measure of aperitif (60 ml)
A disorder strongly associated with osteoporosis. These include rheumatoid arthritis, type I (insulin dependent) diabetes, osteogenesis imperfecta in adults, untreated long-standing hypothyroidism, hypogonadism, or premature menopause (<45 years), chronic malnutrition or malabsorption, and chronic liver disease
Current exposure to oral glucocorticoids, or the individual has been exposed to oral glucocorticoids for more than 3 months at a dose of prednisolone of 5 mg daily or more (or equivalent doses of other glucocorticoids)
According to Baim, the following are risk factors for osteoporosis and osteoporotic fracture:
A prior fragility fracture
Parental history of fracture
Current tobacco smoking
Long-term use of oral glucocorticoids
Rheumatoid arthritis
Secondary causes of osteoporosis
Daily alcohol use of three or more units daily
Advanced age (greater than 65)
Body habitus (weight less that 127 pounds or BMI less than or equal to 20)
Caucasian or Asian race
Hypogonadism
Sedentary lifestyle
Diet deficient in calcium or vitamin D without adequate supplementation
Increased likelihood of falling
Evidence is insufficient to permit conclusions regarding the use of ultrasound densitometry to diagnose osteoporosis.
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). (2007). ACR appropriateness criteria™: Osteoporosis and bone mineral density. Retrieved March 16, 2009 from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/OsteoporosisandBoneMineralDensityUpdateinProgressDoc17.aspx.
Baim, S., Binkley, N., Bilezikian, J.P., Kendler, D.L., Hans, D.B., Lewiecki, E.M., et al. (2008). Official positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD position development conference. Journal of Clinical Densitometry, 11(1), 75-91.
BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2008). Bone mineral density studies. (6.01.01). Retrieved March 3, 2009 from BlueWeb.
Code of Federal Regulations. 42CFR410.31. (2008, October). Bone mass measurement: Conditions for coverage and frequency standards. Retrieved March 16, 2009 from http://edocket.access.gpo.gov/cfr_2008/octqtr/42cfr410.31.htm.
Complete Guide to Medicare Coverage Issues [Computer software]. (2008, November). Bone (mineral) density studies, (NCD 150.3, pp. 2-66).The Ingenix Complete Guide to Medicare Coverage Issues.
ECRI Institute. Health Technology Assessment Information Service. Evidence Reports. (2000, February). Ultrasound bone densitometry for diagnosis of osteoporosis. Retrieved April 11, 2003 from ECRI Institute. (65 articles and/or guidelines reviewed).
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.
Institute for Clinical Systems Improvement. (2000, January). Densitometry as a diagnostic tool for the identification and treatment of osteoporosis in women. Retrieved March 16, 2009 from http://www.icsi.org/guidelines_and_more/technology_assessment_reports/technology_assessment_reports_-_active/densitometry_as_a_diagnostic_tool_for_the_identification_and_treatment_of_osteoporosis_in_women.html.
Institute for Clinical Systems Improvement. (2008, September). Diagnosis and treatment of osteoporosis. Retrieved March 16, 2009 from http://www.icsi.org/osteoporosis/diagnosis_and_treatment_of_osteoporosis__3.html.
Medicare Benefit Policy Manual. Retrieved March 23, 2009 from http://www.cms.hhs.gov/Manuals/downloads/bp102c15.pdf.
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. (2008). Clinician’s guide to prevention and treatment of osteoporosis. Retrieved March 23, 2009 from http://www.nof.org/professionals/NOF_Clinicians_Guide.pdf.
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.
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.
World Health Organization. (2007). WHO Scientific Group on the assessment of osteoporosis at primary health care level. Retrieved March 23, 2009 from http://www.who.int/chp/topics/Osteoporosis.pdf.
ORIGINAL EFFECTIVE DATE: 12/1985
MOST RECENT REVIEW DATE: 9/13/2009
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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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