CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover

Defines medical necessity and coverage stance for measurement of bone turnover markers (serum/urine tests such as collagen crosslinks and osteocalcin) for diagnosis and management of osteoporosis and conditions with high bone turnover across BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover

Policy CodePolicy N/A

Change Typeclarified

Effective DateJan 1, 2011

Next Review Date

Key ActionPrior authorization review is not required for measurement of bone turnover markers; for Commercial claims, document clinical rationale if pursuing testing when filing CPT codes 82523 or 83937 with diagnoses M81.0-M81.8 or Z13.820.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 02/06/2020; BlueCHiP for Medicare covers the listed CPT codes while Commercial products consider these tests not medically necessary for specified indications.

2CPT codes referenced

2Not medically necessary diagnosis groups (Commercial)

1Payer product distinction

Coverage Summary

This policy defines coverage distinctions for measurement of bone turnover markers (serum/urine tests such as collagen crosslinks and osteocalcin) between payer products: BlueCHiP for Medicare covers measurement of bone turnover markers and lists specific CPT codes as medically necessary, while Commercial products consider these tests not medically necessary for specified indications and diagnoses.

Overall the coverage stance is mixed: Medicare coverage is allowed for the listed CPT codes, but Commercial plans generally categorize the same CPT codes as not medically necessary when filed with the specified diagnosis codes (e.g., M81.0-M81.8, Z13.820).

Effective Date2011-01-01

Last Review2020-02-06

Policy SubjectBone turnover marker testing for osteoporosis and high bone turnover diseases

Medical Necessity Criteria

BlueCHiP for Medicare - Medical Necessity

Covered when the following CPT codes are submitted:

BlueCHiP for Medicare coverage

Coverage statement: Measurement of bone turnover markers is covered under BlueCHiP for Medicare.
Covered CPT codes: The following CPT codes are medically necessary: 82523 Collagen cross links, any method; 83937 Osteocalcin (bone gla protein).

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title": "BlueCHiP for Medicare - Medical Necessity

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Commercial Products - Not Medically Necessary Indications

Measurement of bone turnover markers is considered not medically necessary for the following indications (Commercial products):

Commercial not medically necessary indications

Response to therapy: To determine response to therapy in patients who are treated for osteoporosis.
High bone turnover conditions
- Examples: Includes but is not limited to Paget disease, primary hyperparathyroidism, and renal osteodystrophy.
Fracture risk assessment: To determine fracture risk in patients with osteoporosis or with age-related risk factors for osteoporosis.

General Clinical Rationale / Evidence Summary

Rationale statements supporting coverage decisions:

Rationale and evidence summary

Insufficient evidence for improved outcomes: Insufficient evidence that bone turnover marker measurement improves patient management or health outcomes (e.g., reduces fracture rates).
Insufficient evidence for adherence/management impact: Insufficient evidence that testing improves adherence to treatment or impacts management decisions.
Associations not validated for individual guidance: Markers may be associated with fracture risk in some groups, but insufficient evidence for any specific marker to guide individual treatment reliably.

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Provider Actions

Prior Authorization

Prior authorization not required

Prior authorization review is not required for measurement of bone turnover markers.

Documentation Required

Use appropriate diagnosis codes for Commercial claims

For Commercial products, claims for CPT codes 82523 and 83937 filed with diagnoses in the ranges M81.0-M81.8 or Z13.820 are considered not medically necessary and may be denied; providers should document clinical rationale if pursuing testing outside Medicare coverage.

82523
83937
M81.0-M81.8
Z13.820
Denial risk: Commercial claims filed with these diagnosis codes may be denied

Background

Bone turnover markers are biochemical indicators of bone formation or bone resorption that can be measured in serum or urine (examples include collagen crosslinks and osteocalcin). They have been proposed as adjuncts to bone mineral density (BMD) for estimating fracture risk and as earlier indicators of treatment response than changes in BMD.

However, the policy notes important evidence limitations: although marker levels may be associated with fracture risk in some groups and can change earlier than BMD, there is insufficient evidence that any specific marker reliably guides individual treatment, that marker testing improves adherence or management decisions, or that it improves health outcomes such as reducing fracture rates.

Bone turnover markersBiochemical markers indicating bone formation or bone resorption measured in serum or urine (examples: collagen crosslinks, osteocalcin).

The evidence strength summary states there is insufficient evidence that measurement of bone turnover markers improves patient management or health outcomes; while associations with fracture risk have been observed in some groups, they are not validated for specific markers to guide individual treatment.

Name	Type	Effective Date
Collagen Crosslinks, any Method	NCD	2017-11-30

Revision History

11/01/2011Policy effective

Policy effective date established.

08/2015Provider update

Provider Update issued (August 2015).

02/2017Provider update

Provider Update issued (February 2017).

08/2018Provider update

Provider Update issued (August 2018).

04/2020Provider update

Provider Update issued (April 2020).

02/06/2020Policy last updatedLatest

Policy last updated 02/06/2020; clarifies that BlueCHiP for Medicare covers specified CPT codes while Commercial products consider these tests not medically necessary for listed indications.