CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Bone Mineral Density (BMD) Studies

Defines coverage, medical necessity stance, and coding for bone mineral density testing (DXA, QCT, ultrasound, SPA/DPA) for Medicare Advantage and Commercial products of Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyBone Mineral Density (BMD) Studies

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review DateSep 17, 2025

Key ActionPrior authorization is not required for bone mineral density studies; document use of covered CPT codes 77081 or 77085 for commercial products and ensure DXA is performed on a device capable of central (hip/spine) imaging with permanent image storage and interpretation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

DXACore covered modality

78350/78351SPA/DPA not covered

Not requiredPA requirement

RequiredCentral DXA necessity

QCT/USOther techs not med. necessary

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Coverage Criteria

Indications for initial BMD assessment (central DXA)

Covered when ANY of the following apply (initial measurement at hip or spine may be considered medically necessary):

Age-based screening: Women age >=65 or Men age >=70 regardless of other risk factorswomen >=65; men >=70

central DXA

Younger individuals with risk factors: Younger postmenopausal women and men age 50-70 about whom there is clinical concern based on risk factorswomen <65 with concern; men 50-70 with concern

central DXA

Adults with conditions or medications associated with low bone mass: Adults with a condition or taking a medication associated with low bone mass or bone loss (e.g., long-term glucocorticoids, endocrine disorders)clinical judgment

central DXA

Computed tomography–based bone mineral density (BMD) studies and ultrasound bone density measurement are not considered medically necessary for Commercial Products because the evidence is insufficient to determine effects on health outcomes. Dual‑energy X‑ray absorptiometry (DXA) of central sites (hip and spine) remains the preferred modality for diagnosis and monitoring; peripheral DXA may be covered in select situations but CT and ultrasound modalities lack evidence of improving net health outcomes.

The following procedure codes are designated not medically necessary for Commercial Products: 76977 (ultrasound bone density measurement and interpretation), 77078 (CT bone mineral density study), G0130 (single‑energy X‑ray absorptiometry), and codes for CT finite element analysis (0554T–0558T). Claims using these codes may be denied due to insufficient evidence that these modalities improve health outcomes compared with central DXA.

Single‑ and dual‑photon absorptiometry (SPA/DPA), ultrasound densitometry (for Commercial Products), and computed tomography–based BMD studies (including QCT and CT finite element analyses) are considered not medically necessary or not covered when used in place of central DXA because current evidence does not demonstrate an improvement in clinically meaningful outcomes. Central DXA of the hip and spine is preferred for initial diagnosis and repeat assessment of osteoporosis.

For Commercial Products, the use of the specific codes 76977, 77078, G0130, and 0554T–0558T is explicitly listed as not medically necessary. Providers should submit claims with covered DXA CPT codes when appropriate and be aware that claims with these listed codes may be denied.

Coding and Billing

Not covered / Not medically necessary (Medicare Advantage & Commercial)CPTNot Covered

78350	Bone density (bone mineral content) study, one or more sites; single photon absorptiometry (SPA)
78351	Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry (DPA)

Covered CPT Codes (Commercial Products)CPTCovered

77081	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77085	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment

Not medically necessary (Commercial Products)mixedNot Covered

76977	Ultrasound bone density measurement and interpretation
77078	Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
G0130	Single energy X-ray absorptiometry (SEXA) bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel)
0554T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data, assessment of bone strength and fracture risk and bone mineral density, interpretation and report
0555T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data
0556T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; assessment of bone strength and fracture risk and bone mineral density
0557T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; interpretation and report
0558T	Computed tomography scan taken for the purpose of biomechanical computed tomography analysis

Covered CPT CodesCPTCovered

77081	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77085	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment

Not Medically Necessary CodesmixedNot Covered

76977	Ultrasound bone density measurement and interpretation
77078	Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
G0130	Single energy X-ray absorptiometry (SEXA) bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel)
0554T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data, assessment of bone strength and fracture risk and bone mineral density, interpretation and report
0555T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data
0556T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; assessment of bone strength and fracture risk and bone mineral density
0557T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; interpretation and report
0558T	Computed tomography scan taken for the purpose of biomechanical computed tomography analysis

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization Not Required

Prior authorization is not required for bone mineral density (BMD) studies.

Billing Rule

Coverage by CPT Code

Commercial coverage: Document and bill covered DXA procedures using CPT codes 77081 and 77085 for commercial products. For Medicare Advantage Plans, refer to the Preventive Services for Medicare Advantage Plans policy for applicable CPT codes.

Covered CPT: 77081, 77085
For Medicare Advantage Plans, see related Preventive Services policy

Background

Bone mineral density (BMD) testing is used to identify individuals with osteoporosis and to monitor response to therapy with the goal of reducing fracture risk. Dual‑energy X‑ray absorptiometry (DXA) of central sites (hip and spine) is the most predictive modality for fragility fractures and is the preferred method for initial diagnosis and repeat assessments. Other modalities such as peripheral DXA, quantitative computed tomography, and ultrasound densitometry exist but have less evidence that they identify patients who will benefit from pharmacologic treatment or that repeat measurements with these technologies improve clinical outcomes.

Definitions

T score — definition and WHO diagnostic thresholds

DefinitionT score = the standard deviation difference between an individual's BMD and that of a young-adult reference population.

WHO diagnostic threshold - OsteoporosisT score ≤ -2.5 indicates osteoporosis based on WHO thresholds.

UseT score is used to compare BMD to a young-adult reference population and inform WHO diagnostic categories and fracture risk assessment.

Central DXA — hip and spine (axial) measurements

DefinitionDual-energy X-ray absorptiometry measurement of axial sites (hip and spine).

Requirement for diagnosisCentral DXA of the hip and spine is required for the initial diagnosis and for repeat BMD assessments.