CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Vertebral Fracture Assessment (VFA) without Densitometry

This policy governs coverage and medical necessity determinations for vertebral fracture assessment (VFA) performed without concurrent bone mineral density (densitometry) and affects providers submitting claims to Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyVertebral Fracture Assessment (VFA) without Densitometry

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2015

Next Review DateN/A

Key ActionVerify member-specific benefits and eligibility with the carrier before ordering VFA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

77086CPT code referenced for VFA

Not medically necessaryCommercial stance

Covered (bundled)Medicare Advantage stance

20-30%Clinically recognized fractures

Coverage Criteria

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Medicare Advantage: Vertebral fracture assessment via DXA (CPT 77086) is covered but not separately reimbursed for Medicare Advantage plans.

77086 covered but bundled with BMD study reimbursement rules apply.

Commercial Products: Screening VFA without a bone density study is considered not medically necessary for Commercial Products due to insufficient evidence of improved health outcomes.

Commercial plans may deny claims for standalone VFA (77086).

The rationale is that evidence is insufficient to determine the effects of VFA performed without concurrent bone mineral density testing on health outcomes. Because the clinical benefit of screening with VFA alone has not been established, standalone VFA for screening is considered not medically necessary for Commercial Products.

When performed with DXA densitometry to augment fracture risk assessment

When performed with DXA densitometry to augment fracture risk assessment: VFA performed with DXA densitometry may be used to assess vertebral fractures at the time of bone mineral density testing to identify fractures not clinically recognized; diagnostic accuracy data exist but direct evidence that adding VFA to densitometry improves health outcomes is insufficient.

VFA uses lower radiation than standard radiographs and is intended to be performed in conjunction with a DXA BMD study.

Provider Actions

Prior Authorization

Prior authorization is not applicable for this policy.

Note

Verify Member Benefits

Benefits and coverage vary by contract. Verify the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for specific benefits and coverage before providing services.

Call the provider call center for member-specific eligibility and benefit information.
Do not rely solely on this policy for coverage determinations; the member's contract supersedes this policy.

Denial Risk

Denial Risk — Standalone VFA Screening

Screening VFA (vertebral fracture assessment) without a bone density (DXA) study is considered not medically necessary for Commercial Products and may be denied. Providers should document medical necessity or perform VFA in conjunction with DXA when appropriate.

Commercial Products: VFA without bone density is Not Medically Necessary — denial risk for standalone VFA screening.
If services are denied as not medically necessary and you proceed, you may not bill the member unless they have been informed and agreed in writing to pay.
Refer to the member's Subscriber Agreement or employer contract for final coverage determination.

Documentation Required

Provider Billing & Contract Requirements

If a service is determined to be not medically necessary or non-covered, providers must follow contractual requirements regarding member billing and advance written consent.

Do not charge members for non-covered services unless you have informed them and obtained written agreement in advance.
Refer to your participation agreement(s) for applicable billing and contractual provisions.

Note

Policy Notice

This policy is for informational purposes and is not a guarantee of payment. Coverage decisions are made based on the member's specific plan documents.

BCBSRI may review and revise this policy at any time.
Contact the provider call center for member-specific questions.

Not Covered / Exclusions

NOT COVERED: Standalone VFA (DXA lateral spine) without a concurrent bone density study for screening is not covered and is considered not medically necessary for Commercial Products. (Note: policy language differentiates product types; for Medicare Advantage plans VFA may be covered but is not separately reimbursed.)

Background

Vertebral fractures are common in older adults and many are clinically unrecognized; only about 20–30% are identified clinically. Lateral spine imaging, including vertebral fracture assessment (VFA) performed with a DXA densitometer, can detect these fractures and uses lower radiation than standard radiographs. However, when VFA is performed it is intended to be used in conjunction with bone mineral density testing to augment fracture risk assessment, and standalone screening VFA adds cost and radiation without established evidence of improved health outcomes.

Definitions

Genant semiquantitative grading — grade thresholds and descriptions

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

VFA (vertebral fracture assessment) — definition and alternative names

DefinitionLateral spine imaging performed with a DXA densitometer that uses lower radiation exposure than standard radiographs to detect vertebral fractures

Alternative namesInstant vertebral assessment; radiographic vertebral assessment; dual-energy vertebral assessment; lateral vertebral assessment

Typical usePerformed in conjunction with dual-energy X-ray absorptiometry (DXA) bone density testing to assess for vertebral fractures