Bone Mass Measurements
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Clinical policy governing when bone mass measurements (e.g., DXA, QCT, ultrasound) are considered medically necessary, investigational, or not indicated for Aetna members; applies to providers ordering and performing bone density testing.
No material clinical or coverage changes in this revision.
Coverage Criteria for Bone Mass Measurements
Medical Necessity Indications
Covered when ANY of the following are met:
Monitoring response to osteoporosis drug therapy is covered only by DXA.
Repeat Measurement Exceptions
More frequent bone mass measurements are allowed when ALL of the following contexts are present (one or more may apply):
Repeat testing is otherwise usually not indicated more frequently than once every 2 years.
Simultaneous Axial and Appendicular Measurements
Simultaneous axial and appendicular measurements covered only when ANY of the following are met:
Simultaneous axial and appendicular measurements have no proven value for other indications.
Permitted Measurement Methods
Established/covered measurement methods:
Certain listed modalities (eg, DPA, DXL, SPA, pulse‑echo ultrasound/Bindex) are considered experimental/investigational and not covered.
Evidence-informed coverage considerations
Coverage considerations informed by evidence and guideline excerpts in this document segment:
Ehrlichman and Holohan (1996) analysis.
USPSTF (2011); ACP (Qaseem et al, 2008).
Jamal (2010) and Ehrlichman and Holohan (1996).
Karjalainen et al (2016); Schousboe et al (2017); de Klerk et al (2009).
European Association of Urology (Dohle et al, 2012).
Summary conclusions (evidence to-date)
Key conclusions relevant to clinical utility and potential coverage implications:
Westbury et al (2019).
FDA 510(k) summary and policy background.
WHI cohort analysis (mean follow‑up ~9 years).
Small preliminary studies; further validation needed.
TBS evidence summaries.
Multiple studies (n up to ~1,214); causation and outcome impact not established.
Bone mass measurement for indications other than those specifically listed in the policy (for example, evaluation of osteoporosis or osteoporotic fractures in persons with schizophrenia who are on antipsychotic medications, or routine monitoring of individuals receiving antidepressant therapy) is considered experimental and investigational because the effectiveness of these approaches has not been established. The policy explicitly lists these and other modalities (DPA, DXL, SPA, pulse-echo ultrasound) as investigational when used for such off‑label indications.
Routine bone mineral density (BMD) testing in patients with chronic kidney disease, particularly those with CKD stages 4 and 5, is not supported. The evidence cited indicates that BMD measurements do not reliably differentiate uremic bone disease or predict fracture risk in renal osteodystrophy, and thus currently do not provide useful information to support therapeutic decisions in these patients; clinicians should not routinely order BMD testing in CKD patients.
Finite element analysis (FEA) using QCT-derived models can estimate bone strength and has predictive value in research settings, but FEA cannot be used to diagnose osteoporosis, initiate therapy, or monitor therapy. These techniques remain primarily research tools and their role in routine clinical practice has not been defined.
The referenced sections summarize research findings (for example, associations of skin autofluorescence [SAF] or urinary phthalate biomarkers with lower BMD or fracture risk) and emphasize limitations such as lack of causal proof, limited generalizability, and need for prospective validation. These excerpts do not themselves establish explicit coverage exclusions but indicate that SAF measurement and urinary phthalate testing are investigational pending further confirmatory studies.
Clinical Policy Bulletins are intended to assist in administering plan benefits but are not contracts and do not replace plan provisions. Actual coverage determinations depend on the member’s specific plan provisions; the policy is a partial description and providers should rely on plan terms when determining coverage.
Radiological computer-assisted prioritization/AI software (for example, HealthVCF) is described as a triage and prioritization tool for flagging suspected vertebral compression fractures on chest or abdominal CTs. Such tools are not medically necessary as replacements for clinician evaluation because they do not provide diagnostic confirmation and final interpretation must rest with the treating clinician.
Yearly densitometry (annual DXA) is unlikely to be clinically indicated given typical measurement precision and expected rates of bone loss. Precision errors are commonly in the 2–3% range while annual bone loss is usually 1–2%, yielding a minimum interval to document true bone loss on the order of approximately 3.7 to 6 years; there are no clinical data demonstrating improved outcomes from annual screening.
Routine repeat DXA testing about 3 years after the initial screening in post‑menopausal patients without osteoporosis is not supported by the evidence presented. A large cohort study and guideline recommendations conclude that a second BMD assessment at 3 years did not meaningfully improve discrimination of future hip or major osteoporotic fractures beyond the baseline BMD value and therefore should not be routinely performed.
Skin autofluorescence (SAF) as a measure of advanced glycation end‑products (AGEs) and related SAF-AGEage indices show associations with lower BMD and higher prevalence of low bone density or fractures in diabetes cohorts, but the policy notes that these findings require larger prospective studies and further validation before SAF measurement can be considered an established clinical tool.
This portion of the policy contains background material and does not include explicit ‘not medically necessary’ statements for every modality. Where notations of investigational status or non‑supportive evidence are provided, they are meant to inform coverage decisions but do not constitute an exhaustive list of denials; plan provisions and clinical context drive final determinations.
Coding References and Key Values
| 76977 | Ultrasound bone density measurement and interpretation, peripheral site(s), any method |
| 77078 | Computerized tomography, bone mineral density study, 1 or more sites |
| 77080 | Dual energy x-ray absorptiometry (DXA), bone density study, 1 or more sites |
| 77081 | Dual energy x-ray absorptiometry (DXA), bone density study, 1 or more sites |
| 77085 | Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton, including vertebral fracture assessment |
| 77086 | Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA) |
| 77089 | Trabecular bone score (TBS), calculation, with interpretation and report on fracture-risk |
| 77090 | Technical preparation and transmission of data for analysis to be performed elsewhere |
| 77091 | Technical calculation only |
| 77092 | Interpretation and report on fracture-risk only by other qualified health care professional |
| 0508T | Pulse-echo ultrasound bone density measurement resulting in indicator of axial bone mineral density, tibia |
| 0554T | Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; assessment and report |
| 0555T | Retrieval and transmission of the scan data |
| 0556T | Assessment of bone strength and fracture risk and bone mineral density |
| 0557T | Interpretation and report |
| 0691T | Automated analysis of an existing computed tomography study for vertebral fracture(s), including assessment of bone density when performed, data preparation, interpretation, and report |
| 0743T | Bone strength and fracture risk using finite element analysis of functional data and bone mineral density (BMD), with concurrent vertebral fracture assessment, utilizing data from a computed tomography scan; retrieval and transmission of the scan data, measurement of bone strength and BMD and classification of any vertebral fractures, with overall fracture-risk assessment, interpretation and report |
| 0749T | Bone strength and fracture-risk assessment using digital X-ray radiogrammetry-BMD analysis; retrieval and transmission of digital X-ray data, assessment of bone strength and fracture risk and BMD, interpretation and report |
| 0750T | DXR-BMD analysis with single-view digital X-ray of the hand |
| 70486 | Computed tomography, maxillofacial area; without contrast material [not covered for osteoporosis screening] |
| G0130 | Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton |
| E05.00 - E05.91 | Thyrotoxicosis [hyperthyroidism] |
| E20.0 - E20.9 | Hypoparathyroidism |
| E28.39 | Other primary ovarian failure |
| E29.1 | Testicular hypofunction |
| E34.50 - E34.52 | Androgen insensitivity syndrome |
| G40.001 - G40.919 | Epilepsy and recurrent seizures |
| K90.0 | Celiac disease |
| M80.011A – M80.88XS | Osteoporosis with current pathological fracture |
| M81.0 - M81.8 | Osteoporosis without current pathological fracture |
| M84.411A – M84.48XS | Pathologic fracture, not elsewhere classified |
| F20.0 - F20.9 | Schizophrenia |
| F32.0 – F33.9 | Major depressive disorders |
| N18.1 - N18.9 | Chronic kidney disease (CKD) |
| Category III CPT (Bindex) | AMA issued a new Category III CPT code for Bindex measurement (pulse‑echo ultrasound) |
| 42 CFR Part 410 | Medicare Program; Medicare Coverage and Payment for Bone Mass Measurements (regulatory citation referenced) |
| K192901 | FDA 510(k) number referenced for a bone densitometry device (HealthVCF) |
| No codes listed |
Provider Actions, Documentation, and Billing
Bill covered CPT/HCPCS codes when selection criteria are met
Bill the appropriate covered CPT/HCPCS code that corresponds to the modality and clinical indication when the policy’s selection criteria are met; covered codes include central DXA, peripheral ultrasound, CT-based BMD, VFA, and TBS as listed in the policy.
Document prescreening with pulse‑echo ultrasound and act on results
If a pulse‑echo ultrasound device (e.g., Bindex) or other peripheral ultrasound is used as an initial prescreen, document the prescreen result and the fracture‑risk assessment context (for example, FRAX); use the prescreen to determine whether referral for central DXA is needed.
- Bindex is intended to be used alongside FRAX/QFracture to decide whether DXA referral is required.
- Positive or indeterminate prescreen results should prompt referral for DXA per the device/study guidance.
No prior authorization statements in background
Background sections do not state specific prior authorization requirements for DXA or other bone mass measurements; DXA remains the referenced diagnostic standard.
- DXA is identified as the clinical standard for diagnostic classification.
- No PA language appears in the policy background describing mandatory authorizations.
Prior authorization not specified in this excerpt
This document excerpt does not specify plan-level prior authorization rules for bone mass measurement procedures; specific PA requirements are determined by plan provisions and local payer processes.
- The policy text contains background references and coding lists but does not impose explicit PA steps in this excerpt.
Prior authorization guidance references CMS and device 510(k) summaries
Policy references CMS/Medicare guidance and device 510(k) summaries as background; whether a procedure requires prior authorization is determined by plan provisions and may refer to CMS/local coverage decisions.
- FDA 510(k) device summaries (e.g., K192901) and regulatory citations are included for context, not as PA rules.
- Providers should follow plan-specific prior authorization procedures where applicable.
Use ultrasound prescreen then refer for DXA if indicated
Use pulse‑echo ultrasonometry or other peripheral ultrasound as an initial screening step; positive or indeterminate prescreen results should lead to referral for DXA.
- Studies reported that pulse‑echo ultrasonometry could avoid follow-up DXA in ~69–73% of women while detecting hip osteoporosis with ~80–82% sensitivity.
- When used as a prescreen, document whether the result led to avoidance of DXA or to referral for DXA.
No step-therapy specified for SCI-related osteoporosis in background
The background evidence for spinal cord injury (SCI)-related osteoporosis does not specify any required therapeutic sequencing or mandatory trials; no step‑therapy requirements are stated in this extract.
- Available studies show variable and generally low-quality evidence for interventions in SCI-related osteoporosis.
- No policy-mandated step therapy is described for this population in the excerpt.
Routine repeat DXA at ~3 years not supported to improve risk discrimination
Routine short-interval repeat DXA (e.g., around 3 years) did not improve fracture‑risk discrimination beyond baseline BMD alone in the cited cohort; routine repeat testing at short intervals is not supported by this evidence.
- The study concluded a second BMD assessment ~3 years after baseline was not associated with improved discrimination for hip or major osteoporotic fractures.
- Consider baseline BMD when deciding on repeat testing rather than automatic short-interval repeats.
Document rationale for repeat testing intervals (usually ≥2 years)
Repeat bone mass measurements should generally be performed no more frequently than once every 2 years; if more frequent monitoring is done, document the specific clinical rationale.
- Permitted reasons for earlier repeat testing include confirmatory baseline when changing technique, monitoring long-term glucocorticoid or anticonvulsant therapy (>3 months), or uncorrected primary hyperparathyroidism.
- When more frequent monitoring is performed, document the indication and rationale in the medical record.
Document prescreen result and FRAX context when peripheral ultrasound used
When a peripheral prescreen (e.g., pulse‑echo ultrasound/Bindex) is used, document the prescreen result, the fracture‑risk assessment context (such as FRAX), and whether the prescreen outcome led to avoidance of DXA or to referral for DXA.
- Record the device used, measured Density Index or threshold applied, and the decision pathway (no DXA vs. refer for DXA).
- Link prescreen findings to the overall fracture-risk assessment used for the patient (FRAX/QFracture).
Document evidence when linking medications to BMD changes
When citing medication-associated BMD effects, include primary study or meta-analysis details such as study population, measured sites, effect sizes, and confidence intervals as presented in the literature summaries.
- Examples include SSRI studies and meta-analyses where lumbar spine BMD changes and subgroup effects were reported.
- Document the evidence basis when using medication exposure to justify testing or management decisions.
Document clinician review when AI/triage tools flag findings
If AI/triage outputs (e.g., HealthVCF) are used to recall patients for further evaluation, document clinician review of the flagged imaging and the final diagnostic interpretation; AI output alone should not be relied upon for diagnosis.
- HealthVCF provides triage/notification only and does not replace clinician review of the original CT.
- Document that the final diagnosis was made by a clinician after review of the imaging study.
Avoid investigational modalities — risk of noncoverage/denial
Do not order bone mass measurements using DPA, DXL, SPA, pulse‑echo ultrasound (e.g., Bindex) for diagnostic/coverage purposes, cone beam CT, finite element analysis, skin autofluorescence (AGEs), or urinary phthalate testing for fracture‑risk assessment because these modalities are considered experimental/investigational and are not covered.
- Explicitly listed investigational modalities: DPA, DXL, SPA, pulse‑echo ultrasound (Bindex), cone beam CT, finite element analysis, SAF-AGEs, and urinary phthalate testing.
- Claims for these modalities may be denied as not covered per the policy’s investigational list.
Avoid routine BMD testing in advanced CKD (stages 4–5)
Do not routinely order BMD testing for patients with chronic kidney disease stages 4–5; routine BMD testing in CKD is of unclear utility and clinicians should avoid routine ordering in this population.
- BMD testing does not reliably differentiate uremic bone diseases or predict fracture risk in CKD, limiting its clinical utility for therapeutic decisions.
- Document specific clinical justification if BMD testing is performed in CKD patients.
Use DXA as the diagnostic standard; CBCT not supported as substitute
Use DXA as the standard diagnostic tool for BMD measurement and osteoporosis classification; cone beam CT is not supported as a diagnostic alternative in the cited review.
- UpToDate and the policy identify DXA as the technology used for diagnostic classification in clinical practice.
- CBCT is not mentioned as a diagnostic tool for osteoporosis in the referenced review and therefore is not an accepted substitute.
AI triage outputs do not substitute for clinician diagnosis
AI triage tools (e.g., HealthVCF) are for prioritization and do not replace clinician diagnosis; reliance on AI output alone for diagnostic evidence is inappropriate and may lead to noncoverage if used in place of clinician interpretation.
- HealthVCF returns notifications to a worklist and is not diagnostic — the clinician must review the original study for final interpretation.
- There are no peer-reviewed studies showing improved patient outcomes from HealthVCF; document clinician confirmation of findings.
Background and Evidence Summary
Background: Osteoporosis is characterized by low bone density and increased fracture risk in men and women. Post‑menopausal osteoporosis is related to estrogen decline. Dual‑energy X‑ray absorptiometry (DXA) is identified as the clinical standard for bone mass measurement, and older methods (DPA, SPA) have largely been replaced. Precision limits of densitometry mean that frequent (eg, annual) testing is generally not supported and longer intervals are usually required to reliably detect change.
Definitions and Abbreviations
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