CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Vertebral Fracture Assessment

Policy governing coverage and medical necessity of vertebral fracture assessment performed with dual-energy x-ray absorptiometry (DXA/DEXA), addressing BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyVertebral Fracture Assessment

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2015

Next Review DateN/A

Key ActionVerify member benefits and eligibility with the provider call center prior to performing VFA; prior authorization is not applicable but coverage varies by product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

77086CPT referenced

2015-10-01Effective

2018-11-06Last updated

Covered (no separate reimbursement)Medicare stance

Not medically necessaryCommercial stance

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Product-specific coverage

Coverage statements differ by product

BlueCHiP for Medicare: Screening for vertebral fractures using DXA (without an accompanying bone mineral density study) is covered but not separately reimbursed.

77086 covered but not separately reimbursed

Commercial Products: Screening for vertebral fractures using DXA (without an accompanying bone mineral density study) is considered not medically necessary due to insufficient evidence of effect on health outcomes.

77086 not medically necessary for commercial

For Commercial Products, vertebral fracture assessment (VFA) performed with DXA without an accompanying bone mineral density study is considered not medically necessary because the evidence is insufficient to determine an effect on health outcomes.

This policy distinguishes coverage by product type. Specifically, for Commercial Products VFA using DXA when performed without a bone mineral density study lacks sufficient evidence of benefit and therefore is not medically necessary; such services may be denied.

Screening for vertebral fractures

VFA screening indication

Screening for vertebral fractures: VFA augments diagnostic information on fracture risk when performed with bone mineral density; evidence is insufficient that VFA without densitometry improves health outcomes.

No direct screening trials showing health outcome benefit; diagnostic accuracy variable

Definitions

Definition of Vertebral Fracture Assessment (VFA)

DefinitionVertebral fracture assessment (VFA) is a densitometry technique performed with dual-energy x-ray absorptiometry (DXA) using additional software to assess vertebral fractures at the same time as bone mineral density measurement.

Radiation and scopeVFA uses lower radiation than lateral spine radiographs and is intended to detect vertebral fractures rather than other bone or soft tissue abnormalities.

Alternate namesAlso referred to as instant vertebral assessment, radiographic vertebral assessment, dual-energy vertebral assessment, or lateral vertebral assessment (manufacturer terminology).

Procedure noteVFA is typically performed in conjunction with a bone mineral density study on the densitometer; scan technique may involve remaining supine or moving to left decubitus depending on device.

Genant semiquantitative method — Grade definitions

Grade I (mild)20%–24% reduction in vertebral height

Grade II (moderate)25%–39% reduction in vertebral height

Grade III (severe)>= 40% reduction in vertebral height

Fracture definitionA vertebral deformity of at least 20% loss in height is typically considered a fracture

Provider Actions and Billing Notes

Prior Authorization

Prior authorization

Not applicable

Billing Rule

BlueCHiP reimbursement limitation

Screening for vertebral fractures using dual-energy X-ray absorptiometry (DXA or DEXA), without bone density study, is covered for BlueCHiP for Medicare but is not separately reimbursed.

BlueCHiP for Medicare: covered but not separately reimbursed

Denial Risk

Commercial product denial risk

Screening for vertebral fractures using dual-energy X-ray absorptiometry (DXA or DEXA), without bone density study, is considered not medically necessary for Commercial products; services may be denied for Commercial products.

Commercial products: not medically necessary — denial risk for VFA with DXA without a bone density study

Note

Verify benefits

Benefits may vary between groups and contracts. Verify member eligibility and benefits with the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement prior to rendering services.

Confirm member-specific benefits with provider call center or via subscriber documents

Documentation Required

Verify member eligibility and benefits

This medical policy is informational and not a guarantee of payment. Benefits and eligibility are determined by the member's subscriber agreement or employer agreement. For member-specific benefit questions, contact the provider call center. Providers may not bill members for services determined to be not medically necessary unless the member has been informed and provided written agreement in advance.

Background

Vertebral fractures are common in older adults and identifying them can inform fracture-risk management; VFA performed with DXA can augment diagnostic information when obtained concomitantly with bone mineral density testing. However, when VFA is performed without a bone mineral density study the clinical benefit on health outcomes is uncertain, and the evidence does not support routine use of standalone VFA for screening in Commercial populations.