CurrentBlue Cross Blue Shield - MassachusettsPolicy 449

Vertebral Fracture Assessment (VFA) with DXA and Biomechanical CT (BCT) — Coverage Criteria

This policy addresses the use of vertebral fracture assessment performed with dual-energy x-ray absorptiometry (DXA/VFA) and biomechanical computed tomography (BCT) for screening or detection of vertebral fractures and bone strength assessment; it applies to Blue Cross Blue Shield of Massachusetts members and providers across commercial products described.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyVertebral Fracture Assessment (VFA) with DXA and Biomechanical CT (BCT) — Coverage Criteria

Policy CodePolicy 449

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for any inpatient VFA or BCT service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

77085,77086,0743TCPT codes listed as investigational for Commercial members

Not coveredOutpatient commercial coverage stance

RequiredInpatient prior auth required

20%-30%Vertebral fractures clinically recognized

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Coverage and Evidence Statements

Covered when ALL of the following are met:

ALL of the following

Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity - Screening for vertebral fractures using dual x-ray absorptiometry (DEXA or DXA) or biomechanical computed tomography is INVESTIGATIONAL.
Outpatient coverage: For services described in this policy, Commercial Managed Care (HMO and POS), Outpatient = This is not a covered service. Commercial PPO and Indemnity, Outpatient = This is not a covered service.
CPT Codes: 77085 (DXA axial skeleton, including vertebral fracture assessment) is referenced in policy. The following codes are considered investigational for Commercial Members (Managed Care HMO and POS, PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue): 77086 (Vertebral fracture assessment via DXA) and 0743T (Bone strength and fracture risk using finite element analysis / BCT).
Summary of Evidence: Evidence does not demonstrate that routine screening with VFA by DXA or with BCT in people not known to have vertebral fractures improves net health outcomes. Diagnostic accuracy data are variable and there are no clinical trial data showing improved treatment outcomes when fractures are identified solely by VFA or BCT; therefore the evidence is insufficient to support coverage.

Commercial Managed Care (HMO and POS), Outpatient = This is not a covered service. Commercial PPO and Indemnity, Outpatient = This is not a covered service.

Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity — Screening for vertebral fractures using dual x-ray absorptiometry (DEXA or DXA) or biomechanical computed tomography is INVESTIGATIONAL.

No explicit 'not medically necessary' exclusions are stated in this policy; investigational determinations and outpatient noncoverage are used where applicable.

Indications and When Imaging is Considered

Detection of vertebral fractures concurrent with BMD testing

VFA performed concurrently with BMD/DXA may be used to detect vertebral fractures when all applicable conditions below are met:

VFA use cases: Perform vertebral fracture assessment (VFA) at the time of DXA/BMD testing to detect prevalent vertebral fractures and augment fracture risk assessmentGenant grade >=20% height loss considered fracture

Interpretation depends on radiologic training; VFA uses lower radiation than radiographs and detects fractures but not other bone/soft-tissue abnormalities.

CT-derived biomechanical assessment of bone strength and fracture risk

CT-derived biomechanical assessment (BCT) may be performed when the following applies:

BCT use cases: Use BCT (finite element analysis of CT data) to estimate bone strength and classify high or increased fracture risk based on vertebral/hip strength and BMD

CPT / Category III and Code Notes

Investigational CPT Codes (Commercial members)CPTNot Covered

77085

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment

Investigational CPT/Category III Codes (Commercial members and some Medicare products)CPTNot Covered

77086

Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA).

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

No explicit code lists in this sectionmixed

No codes listed

Fragile bone strength — Newton thresholds

Fragile bone strength (definition)Fragile bone strength defined as ≤3000 to 6500 Newtons depending on patient sex and location (hip or spine)

Classification triggerPatients classified as high risk if fragile bone strength or osteoporosis at the hip or spine is found

Dependence on sex/locationThreshold range varies by patient sex and anatomic location (hip versus spine)

Additional coding-related details (BCT outputs)

BCT reporting outputsBCT outputs include femoral neck T-score and Z-score, femoral strength, vertebral strength, vertebral trabecular volume, and vertebral Z-score

Source of data

Prior Authorization, Billing, and Provider Responsibilities

Prior Authorization

Inpatient Prior Authorization Required

For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient. Lack of required precertification/preauthorization may result in denial of payment or prospective review; providers should obtain authorization prior to inpatient admission when applicable.

Inpatient prior authorization required for all products when performed inpatient.
Failure to precertify/preauthorize may trigger claim denial or prospective review.

Denial Risk

Outpatient Noncoverage for Commercial Products

Outpatient VFA/BCT services are not covered for Commercial products in the outpatient setting. Commercial Managed Care (HMO and POS), Outpatient = This is not a covered service. Commercial PPO and Indemnity, Outpatient = This is not a covered service. Providers should bill accordingly and check member contract benefits for coverage determinations.

Precertification / Prior Authorization Rules

Prior Authorization

All inpatient modalities require precertification/preauthorization

Precertification/preauthorization is required for all products if the procedure is performed inpatient; this applies to all imaging modalities when done inpatient.

Obtain precertification for inpatient DXA/VFA or CT/BCT procedures.

Note

No CT prior authorization thresholds specified

These reference sections do not describe specific prior authorization thresholds for CT-based BCT analyses.

Use of Contrast and Imaging Limitations

Billing Rule

Do not use spinal CTs with contrast or transverse-plane metal for BCT

Previously obtained CT scans can be used for BCT analysis in many cases, but spinal images performed with contrast or with metal in the transverse plane are exceptions where BCT may not be possible.

Do not submit CT scans with contrast in the spine or with metal in the transverse plane for BCT unless local lab processes permit it.
Send CT scans to the centralized laboratory for analysis as described.

Note

No specific contrast-administration rules for opportunistic CT/BCT in policy

References include studies using contrast-enhanced CT for opportunistic osteoporosis evaluation, but the policy provides no specific contrast administration rules for BCT.

Be aware that research uses contrast-enhanced CT in some settings, but the policy does not specify contrast administration requirements.

Key Terms and Grading Systems

VFA (vertebral fracture assessment) — definition

DefinitionVertebral fracture assessment (VFA) with densitometry: technique to assess vertebral fractures concurrently with bone mineral density (BMD) using additional software with dual-energy x-ray absorptiometry (DXA)

TimingPerformed at the same time as BMD/DXA measurement

PurposeAugments diagnostic information on fracture risk when added to BMD

BCT — definition and purpose

DefinitionBiomechanical computed tomography (BCT): method using CT scans and non-linear finite element analysis to estimate bone strength and fracture risk

PurposeEstimates femoral and vertebral strength and provides BMD-equivalent outputs to classify fracture risk

Background and Clinical Context

Vertebral fracture assessment (VFA) is an imaging technique performed at the time of bone mineral density (BMD) measurement using DXA that assesses vertebral fractures concurrently with BMD. VFA uses a lower radiation technique compared with conventional radiographs and is intended to detect vertebral deformities commonly graded by semiquantitative systems such as the Genant method.

Services Described as Not Covered

Screening for vertebral fractures using DXA/VFA or BCT is designated as investigational in this policy, and outpatient performance of these services for Commercial products is described as not a covered service. The policy also lists specific procedure codes that are considered investigational for Commercial members.

Frequency and Timing

Frequency limits

Frequency limitsNo frequency limits specified in the policy

ModalityNot stated

PeriodNot stated

References and Revision Notes

Key bibliographic sources cited in support of the policy include clinical studies of VFA and CT-based opportunistic screening and major guideline documents. Representative references include studies combining VFA with DXA (e.g., Mrgan et al., J Clin Densitom. 2013), CT-based screening and validation studies (e.g., Adams et al., J Bone Miner Res. 2018), professional guideline documents (e.g., ACR Appropriateness Criteria 2022; ISCD Official Positions 2023), and the US Preventive Services Task Force screening statement (USPSTF Recommendation, JAMA 2025).