ModifiedAlliance HealthPolicy 1K-2

Bone Mass Measurement (BMM/DXA)

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Coverage criteria, reporting, and special provisions for bone mass measurement (BMM) including DXA, QCT, and ultrasound for NC Medicaid beneficiaries, with pediatric-specific guidance and EPSDT exception language for beneficiaries under 21.

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ModifiedAlliance HealthPolicy 1K-2

Bone Mass Measurement (BMM/DXA)

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Policy Summary

PayerAlliance Health

PolicyBone Mass Measurement (BMM/DXA)

Policy CodePolicy 1K-2

Change TypeMaterial revision — prior authorization removed for BMM

Effective DateN/A

Last ReviewFeb 15, 2024

Next Review DateN/A

Key ActionDo not require prior approval for Bone Mass Measurement; verify beneficiary eligibility and document medical indication in the record.

SourceLink

POLICY UPDATE CHANGES

Medicaid shall not require prior approval for Bone Mass Measurement.

ICD-10 codes and the asterisk information in Attachment A were removed.

No prior approvalNo prior approval

DXA onlyDXA monitoring

3CPTs not covered

T<-2.5Adult osteoporosis threshold

Z<=-2.0Pediatric low BMD

DXA, QCT, USAccepted BMM methods

Coverage Criteria for Bone Mass Measurement

Diagnostic criteria by age group

Covered when meeting established diagnostic criteria for adults and pediatric guidance applies as described:

Adult diagnostic criteria: For postmenopausal women and older men, osteoporosis is diagnosed when T-score <= -2.5 at the lumbar spine, femoral neck, or total hip by DXA; diagnostic categories include Normal (T-score -1.0 and above), Low bone mass/osteopenia (T-score between -1.0 and -2.5), Osteoporosis (T-score -2.5 and below), and Severe osteoporosis (T-score -2.5 and below with history of a fracture).T-score <= -2.5

DXA of the axial skeleton (hip, pelvis, spine) is required for WHO T-score criteria; the 33% radius may be used if spine or hip are not evaluable and is the lowest site measured.

Pediatric diagnostic approach: Do not use T-scores for pediatric DXA reports; use Z-scores adjusted for age, gender and body size. Low BMC or areal BMD is defined as a Z-score <= -2.0. The presence of one or more vertebral compression fractures indicates osteoporosis; in the absence of vertebral compression fractures, a diagnosis of osteoporosis requires both a clinically significant fracture history and a BMD Z-score <= -2.0.Z-score <= -2.0

Clinically significant fracture history is defined as two or more long bone fractures by age 10, or three or more long bone fractures at any age up to 19. T-scores must not appear in pediatric DXA reports and the term 'osteoporosis' should not be used without a clinically significant fracture history.

General and specific medical necessity criteria

Covered when ALL of the following are met

General coverage criteria: The procedure, product, or service is individualized, specific, and consistent with symptoms or a confirmed diagnosis and not in excess of the beneficiary's needs; can be safely furnished with no equally effective, more conservative or less costly statewide treatment available; and is not furnished primarily for convenience.

From general coverage criteria (3.1).

Ordering and setting: Ordered and provided by or under the general supervision of a licensed physician or other licensed non-physician practitioner; provided in an office or similar facility other than a hospital outpatient department or clinic; and performed with a DXA system approved and regulated by the FDA.

From specific criteria (3.2.1 a1–a3).

Medical indications (any one meets criteria): 1) Estrogen-deficient female at clinical risk for low bone mass; 2) Vertebral abnormalities on X-ray indicative of low BMD or fracture; 3) At risk due to long-term medications including: A) glucocorticoid therapy equivalent to >=5.0 mg prednisone per day for three months or greater; B) long-term/excess thyroid replacement therapy with evidence of hyperthyroidism; C) long-term anticonvulsant therapy for three months or greater; D) long-term heparin therapy for one month or greater; E) long-term Depo‑Provera therapy for two years or greater; 4) Primary hyperparathyroidism; 5) Monitoring response to FDA‑approved drug therapy for low BMD; 6) History of fragility or pathologic fracture; 7) Other conditions/therapies known to cause low bone mass (e.g., celiac disease, cerebral palsy, anorexia nervosa, hypogonadism); 8) Peripheral BMD measurement when hip‑spine cannot be done or patient is over table weight limit, or forearm measurement essential for hyperparathyroidism.

For pediatric DXA reports follow pediatric-specific guidance: T-scores must not appear in pediatric DXA reports, and the term "osteoporosis" must not be used without documentation of a clinically significant fracture history. Use age-, sex-, and size-adjusted Z-scores; low BMC/BMD is defined as a Z-score <= -2.0. A diagnosis of osteoporosis in children requires either vertebral compression fracture(s) or both a clinically significant fracture history and a BMD Z-score <= -2.0. Clinically significant fracture history is defined as either ≥2 long-bone fractures by age 10 or ≥3 long-bone fractures by age 19. DXA should only be performed when positioning can be done safely and when results will influence management.

Covered bone mass measurement methods are limited to recognized modalities with DXA of the axial skeleton as the primary test for WHO T-score criteria. Bone mineral density measurement using ultrasound densitometry, quantitative CT, or DXA of peripheral sites is not covered except where explicitly allowed: peripheral BMD testing (for example forearm or 33% radius) may be used when hip or spine cannot be evaluated or when the patient exceeds the DXA table weight limit, and forearm measurement is essential in suspected hyperparathyroidism.

Services that duplicate another provider's procedure, product, or service are not covered. Additionally, procedures that are experimental, investigational, or part of a clinical trial are excluded. Specific not-covered items include bone mineral density measurement by ultrasound densitometry, quantitative CT, and DXA of peripheral sites except where allowed per policy, as well as Pulse-Echo ultrasound density measurement and DXA body composition studies.

The following CPT codes are explicitly not covered for Bone Mass Measurement: 77086, 78350, and 78351.

Use of CPT codes 77086, 78350, and 78351 for bone mass measurement is explicitly listed as not covered and may result in claim denial.

EPSDT allows coverage for medically necessary services for beneficiaries under 21 when needed to correct or ameliorate a condition; however, EPSDT does not require coverage of services that are unsafe, ineffective, or experimental/investigational.

Screening bone mass measurement in individuals at low risk for osteoporosis is considered not medically necessary. Specifically, routine BMM is not covered for females under age 65 or males under age 70 unless they meet the medical necessity criteria listed in the policy (for example specific clinical indications or risk factors).

Coding, Codes, and Key Thresholds

Attachment A: Claims-Related Information (codes and billing guidance)mixed

See Attachment A

Claims-related information, ICD-10-CM/PCS, CPT/HCPCS, Modifiers, Billing Units, Place of Service, Co-payments, Reimbursement (listed in Attachment A)

Referenced CPT codes for DXA/BMMmixed

see Attachment A, Section C	Applicable CPT codes for DXA and other BMM procedures referenced in the policy
77078	covered CPT code (as listed)
77080	covered CPT code (as listed)
77081	covered CPT code (as listed)
76977	covered CPT code (as listed)

Not covered BMM CPT codesmixedNot Covered

CPT codes listed in Attachment A, Section C, C.2	CPT codes for BMM that are not covered (per policy)
77086	CPT not covered
78350	CPT not covered
78351	CPT not covered

Covered CPT CodesCPTCovered

77078	covered CPT code (as listed)
77079	covered CPT code (as listed)
77080	covered CPT code (as listed)
77081	covered CPT code (as listed)
76977	covered CPT code (as listed)

CPTs Not CoveredCPTNot Covered

77086	CPT not covered
78350	CPT not covered
78351	CPT not covered

CPTs not coveredCPTNot Covered

77086	CPT not covered (as listed in policy)
78350	CPT not covered (as listed in policy)
78351	CPT not covered (as listed in policy)

Place-of-service allowanceCPTCovered

76977

Allowed in inpatient, outpatient, physician office, and in addition allowed in beneficiary's primary private residence, intermediate care facility and nursing facility

Adult osteoporosis T-score threshold

ThresholdT-score <= -2.5 (WHO criterion for osteoporosis at lumbar spine, femoral neck, or total hip)

Diagnostic sitesLumbar spine, femoral neck, or total hip

DXA requirementWHO T-score criteria require DXA of the axial skeleton (spine/hip); 33% radius may be used if spine or hip not evaluable

Pediatric low BMD/BMC Z-score threshold

ThresholdBMC or areal BMD Z-score <= -2.0

Provider Actions, Documentation, and Billing Requirements

Prior Authorization

Prior approval for imaging may be required

See related policy 1K-7 for prior authorization requirements that may apply to imaging services, including bone mass measurement (BMM).

Prior Authorization

Prior approval requirement

Prior approval is not required for Bone Mass Measurement; however, EPSDT does not eliminate prior approval when a service normally requires it.

Prior Authorization

Prior Authorization Removed

Medicaid shall not require prior approval for Bone Mass Measurement.

Background and Rationale

Background: Bone Mass Measurement (BMM) quantifies bone mass, monitors changes over time, and helps assess fracture risk and response to therapy. For adults, diagnosis of osteoporosis uses DXA-derived T-score ≤ -2.5 at the lumbar spine, femoral neck, or total hip. In children, densitometric thresholds differ: pediatric interpretation relies on adjusted Z-scores and clinical fracture history rather than adult T-score criteria. BMM (DXA) is used selectively when results will influence management and when safe positioning is possible.

Terms and Definitions

T-score definition

DefinitionT-score: a standardized score comparing bone mineral density to average values of young, healthy women

Diagnostic useUsed to categorize bone density in adults (normal, osteopenia, osteoporosis, severe osteoporosis)

ExpressionResults expressed as T- or Z-scores from BMD testing (DXA required for WHO T-score criteria)

Z-score definition

DefinitionZ-score: a measure of how many standard deviations a raw score is below or above the population mean for age

Pediatric usePreferred for children; must be adjusted for age, gender, and body size and used instead of T-scores in pediatric DXA reports

Policy Summary

PayerAlliance Health

PolicyBone Mass Measurement (BMM/DXA)

Policy CodePolicy 1K-2

Change TypeMaterial revision — prior authorization removed for BMM

Effective DateN/A

Last ReviewFeb 15, 2024

Next Review DateN/A

Key ActionDo not require prior approval for Bone Mass Measurement; verify beneficiary eligibility and document medical indication in the record.

SourceLink

On This Page

From specific indications (3.2.1 b and b8).

Age-only coverage: Female beneficiaries age 65 years or older, or male beneficiaries age 70 years or older, are covered based on age alone.

From Medicaid additional criteria (3.2.2).

Z-scores must be adjusted for age, gender and body size as appropriate

Diagnostic caveatDiagnosis of osteoporosis in children should not be made by densitometric criteria alone; requires vertebral compression fracture or clinically significant fracture history plus Z-score <= -2.0

Glucocorticoid equivalent threshold

ThresholdGlucocorticoid therapy equivalent to >= 5.0 mg prednisone per day for three months or greater

Indication categoryListed as a medication-related risk factor qualifying for BMM when documented in the health record

Documentation requirementHealth record must document long-term (anticipated or actual) glucocorticoid exposure meeting the threshold

Heparin therapy threshold

ThresholdLong-term heparin therapy for one month or greater

ContextConsidered a medication-related risk factor qualifying the beneficiary for BMM when documented

Documentation requirementHealth record must document duration of heparin therapy to meet the one-month threshold

Depo-Provera threshold

ThresholdLong-term Depo‑Provera therapy for two years or greater

ContextListed among medication-related risks that justify BMM when health record documents duration

Documentation requirementRecord must show Depo‑Provera use of two years or longer to meet indication

Anticonvulsant therapy threshold

ThresholdLong-term anticonvulsant therapy for three months or greater

ContextAnticonvulsant use of specified duration is a medication-related risk factor qualifying for BMM

Documentation requirementHealth record must document anticonvulsant therapy duration of three months or more

Billing Rule

Place-of-service allowance for 76977

CPT code 76977 may be provided in additional places of service including the beneficiary's primary private residence, intermediate care facility, and nursing facility; verify place-of-service requirements and any applicable prior authorization rules.

Note

EPSDT considerations

For beneficiaries under 21, EPSDT requires coverage of medically necessary services to correct or ameliorate a condition, but excludes services that are unsafe, ineffective, or experimental.

Note

No specific provider action

No provider action specified in the policy for this item.

Note

Additional Limits

No additional limitations or requirements apply to Bone Mass Measurement under this policy.

Billing Rule

Modifiers and billing units

Providers must follow applicable modifier guidelines and report the appropriate billing units determined by the codes used.

Documentation Required

Baseline DXA report elements checklist

Baseline DXA reports must include manufacturer/model/software version; referring provider; beneficiary age, gender, race/ethnicity, weight, and height; relevant medical history including prior fractures; indication for study; Tanner stage if available; technical quality; BMC and areal BMD; BMC or areal BMD Z-score; source of reference data for Z-score calculations; adjustments made for growth and interpretation; and optional recommendations for timing of the next DXA.

Documentation Required

Documentation requirement: medical indication

The health record must document that the beneficiary meets at least one medical indication for BMM (for example: estrogen-deficient female at clinical risk; vertebral abnormalities on X-ray; long-term medication risks as specified; primary hyperparathyroidism; monitoring response to FDA‑approved therapy; history of fragility/pathologic fracture; or other conditions/therapies known to cause low bone mass).

Documentation Required

EPSDT documentation for under-21

For beneficiaries under 21, providers must document EPSDT medical necessity to exceed policy limitations; prior approval requirements still apply when applicable.

Billing Rule

Coding specificity and unlisted codes

Report ICD-10-CM and PCS codes to the highest level of specificity that supports medical necessity and use current CPT/HCPCS and UB-04 specifications; if no specific code exists, report the appropriate unlisted procedure code per current codebook instructions.

Billing Rule

Unlisted procedure reporting requirements

When using unlisted CPT or HCPCS procedure codes, follow the current CPT and HCPCS instructions for unlisted procedures and submit any required special report per the codebook guidance.

Denial Risk

Eligibility verification required

Verify that the beneficiary is enrolled in NC Medicaid and confirm eligibility at the time of service; services may be denied if eligibility is not verified.

Denial Risk

Denial conditions

Claims may be denied if the beneficiary does not meet policy eligibility in Section 2.0, does not meet medical criteria in Section 3.0, the procedure duplicates another provider's service, or the service is experimental/investigational/part of a clinical trial.

Denial Risk

Denial for younger beneficiaries without medical necessity

Claims for BMM will be denied for female beneficiaries under age 65 or male beneficiaries under age 70 who do not meet the medical necessity criteria in Subsection 3.2.1.

Denial Risk

Coding and billing noncompliance

Claims and institutional billing must comply with National Coding Guidelines and Institutional claims must be billed according to the National Uniform Billing Guidelines; failure to follow these guidelines may trigger denials.

Denial Risk

Not covered CPT codes

Claims submitted with CPT codes 77086, 78350, or 78351 are listed as not covered and risk denial.

Diagnostic caveatLow BMC/BMD defined as Z-score <= -2.0 in pediatric populations

Areal BMD definition

DefinitionAreal BMD: bone mineral content measured by DXA divided by the bone area in square centimeters

ReportingAreal BMD and BMC Z-scores are reported on pediatric DXA when applicable

InterpretationAreal BMD Z-scores <= -2.0 indicate low bone mineral density in children (with clinical correlation)

General supervision definition per 42 CFR 410.32(b)(3)(i)

DefinitionGeneral supervision: as defined in 42 CFR 410.32(b)(3)(i) required when ordered and provided by or under the supervision of a licensed physician or other licensed non-physician practitioner

Ordering requirementBMM must be ordered and provided by or under general supervision per policy

Regulatory referenceSee 42 CFR 410.32(b)(3)(i) for the formal regulatory definition