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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyBlue Cross Blue Shield SD DXA BIA Coverage Update …
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    Currentblue cross blue shield - south dakotaPolicy N/A

    Body Composition (DXA and BIA) Coverage Criteria

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    This policy governs the use and coverage stance for whole-body dual-energy x-ray absorptiometry (DXA) and bioelectrical impedance analysis (BIA) body composition studies for clinical indications among Wellmark members.

    Policy Summary
    Payerblue cross blue shield - south dakota
    PolicyBody Composition (DXA and BIA) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeAnnual reviewrenewed (Nov 2025 noted)
    Effective DateSeptember 2013
    Last ReviewNov 1, 2025
    Next Review Date
    Key ActionSeek prior authorization when DXA is used for body composition assessment if results will directly influence management (examples: sarcopenia, cachexia, malabsorption, cancer, eating disorders, HIV lipoatrophy, or post-bariatric evaluation).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Investigationalcoverage stance
    Nov 2025evidence search
    Sep 2013policy origin
    Nov 2024last revision
    0RCTs for utility
    0358Tlisted CPT

    Coverage Determinations and Criteria

    Investigational / Not clinically useful

    Covered when the evidence demonstrates benefit; current policy stance and evidence summary:

    Investigational policy statement: Whole-body DXA and BIA body composition studies are considered investigational for all indications because the evidence is insufficient to determine that use of these tests improves net health outcomes.

    Policy statement from document.

    DXA evidence limitations: Studies were primarily conducted in research settings and often used DXA as a reference standard; no studies were identified in which DXA body composition measurements were actively used to guide patient management or demonstrated improved outcomes.

    Summary of evidence for DXA.

    BIA evidence limitations: Comparative studies show moderate-to-high correlation with reference methods in some populations, but no studies have demonstrated that BIA use in management improves net health outcomes; clinical utility is unproven.
    Policy Summary
    Payerblue cross blue shield - south dakota
    PolicyBody Composition (DXA and BIA) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeAnnual reviewrenewed (Nov 2025 noted)
    Effective DateSeptember 2013
    Last ReviewNov 1, 2025
    Next Review Date
    Key ActionSeek prior authorization when DXA is used for body composition assessment if results will directly influence management (examples: sarcopenia, cachexia, malabsorption, cancer, eating disorders, HIV lipoatrophy, or post-bariatric evaluation).
    SourceLink
    On This Page
    Coverage Determinations and CriteriaBilling and CodingWhat Providers Must Do / Operational GuidanceBackground and RationaleDefinitions and Key TermsDocument History

    Summary of evidence for BIA.

    Study eligibility for clinical validity evaluation

    Included studies for clinical validity must meet ALL of the following:

    Study selection criteria: Study reports accuracy of the marketed version of the technology (including algorithms); includes a suitable reference standard; describes patient/sample clinical characteristics; describes patient/sample selection criteria.

    From Study Selection Criteria.

    Clinical validity requirement: A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse) to be considered clinically valid.

    Definition of clinically valid from document.

    Initial/Serial Monitoring

    Covered when used to monitor disease-related body composition changes in patients where serial measurements will inform management decisions and alternatives are inadequate:

    Serial DXA monitoring criteria: 1) Patient has a clinical condition managed by monitoring body composition changes over time (e.g., conditions where management may be informed by body composition). 2) Serial whole-body DXA studies are ordered with intent to monitor change and potentially alter management. 3) No adequate alternative method is available or alternatives are insufficient for the intended clinical decision-making.

    Intended purpose and comparator context from clinical context and interventions.

    Clinical utility and evidence requirements

    Summary of evidence-based coverage considerations:

    Evidence requirements for clinical utility: Covered when randomized controlled trial evidence shows that use of DXA to guide management improves net health outcomes OR when a valid chain of evidence exists from demonstrated clinical validity to improved outcomes; currently no RCTs identified and a chain of evidence cannot be constructed because clinical validity is insufficiently established.

    Direct evidence (RCTs) and chain-of-evidence requirements from document.

    General coverage determination

    Evidence summary for use of DXA and BIA in assessing whole-body composition:

    Overall evidence: No direct evidence that using serial DXA or BIA to guide management improves health outcomes; clinical validity for DXA in the monitored populations cannot be established, and BIA lacks studies demonstrating clinical utility.

    Synthesis of systematic reviews and clinical utility findings.

    DXA indications

    DXA total-body composition with regional analysis may be considered when ALL of the following apply:

    DXA indicated: Test is ordered for a clinical condition where results are likely to directly influence management (examples: sarcopenia, cachexia, malabsorption, cancer, eating disorders, HIV with antiretroviral-associated lipoatrophy, or obese patients undergoing bariatric surgery or anticipated large weight loss >~10%).

    ACR, ASPEN, and ISCD contexts noting potential appropriate uses and uncertainty of impact on outcomes.

    Limitations of BIA and ultrasound

    Consider that ALL of the following are true for avoiding certain methods:

    BIA/Ultrasound limitations: Bioelectrical impedance analysis and ultrasound have insufficient or very low quality evidence for some clinical populations; NICE advises not to use bioimpedance as a substitute for BMI in adults and children.

    ASPEN found low/very low quality evidence for ultrasound and limited evidence for BIA; NICE guidance advises against substituting bioimpedance for BMI.

    No condition-specific exclusions are listed in the policy. The document acknowledges multiple potential clinical applications for body composition testing (e.g., anorexia nervosa, cachexia, HIV lipoatrophy, bariatric surgery follow-up) but states the overall policy position that whole-body DXA and BIA body composition studies are investigational for all indications because evidence is insufficient to demonstrate improved net health outcomes.

    Comparators used in the evidence review and for clinical decision-making are limited to standard of care without DXA or alternative body composition methods. The policy advises considering whether less invasive or standard measures were attempted before relying on DXA or BIA, and to compare DXA/BIA results against usual-care approaches when assessing utility.

    The policy does not support the use of DXA for general population screening or in situations where test results will not affect clinical management. Available studies were primarily research-focused, and no randomized trials showed that DXA-guided testing changes management or improves outcomes, so routine screening or testing that will not influence care is not supported.

    Studies that assessed serial whole-body DXA were observational and designed to measure body composition changes rather than to evaluate test accuracy or to inform treatment decisions. None of the identified serial-DXA studies used DXA results to guide patient management, limiting conclusions about clinical utility.

    There is no direct evidence that serial DXA or BIA monitoring of body composition improves health outcomes. The review found no randomized controlled trials demonstrating clinical benefit from using serial DXA or BIA to guide management, and therefore routine monitoring for the purpose of improving outcomes is not supported.

    Pregnancy is a stated contraindication to using DXA for body composition measurement. The ISCD position described in the document explicitly notes that pregnancy is a contraindication to DXA body composition testing.

    Within the cited document sections referenced here, no separate or additional explicit coverage criteria or medical‑necessity rules beyond the overall investigational stance are provided.

    The policy concludes that whole‑body DXA and BIA studies are investigational and not medically necessary for all indications because the evidence does not demonstrate that use of these tests improves net health outcomes or reliably informs management across the populations reviewed.

    Pooled analyses demonstrated high heterogeneity and wide limits of agreement between DXA and reference methods for intra‑abdominal adipose tissue assessment (e.g., I2 up to 99% and pooled mean differences with wide 95% limits of agreement), indicating variable and uncertain DXA estimates in some populations.

    Serial DXA is not considered medically necessary when there is no evidence that test results change patient management. The evidence base lacked RCTs and did not include studies using DXA findings to direct care, so serial testing without demonstrated management impact is not supported.

    DXA use for monitoring changes in body composition or for breast cancer risk assessment in postmenopausal women is not supported by direct evidence of clinical utility. Although cohort studies using DXA exist, the impact of DXA measurements on clinical outcomes in these contexts remains uncertain.

    Monitoring changes with DXA or BIA is considered not medically necessary when the claimed purpose is to improve management or outcomes, because the chain of evidence linking test performance to beneficial patient outcomes is lacking for DXA and direct utility evidence is absent for BIA.

    Per NICE guidance cited in the review, using bioelectrical impedance analysis as a substitute for BMI to measure general adiposity is not supported.

    In the portions of the document corresponding to these chunks there are no additional explicit statements labeling specific uses as not medically necessary beyond the broader investigational stance; the policy primarily presents evidence summaries and guidance rather than a detailed list of medical‑necessity rules.

    Billing and Coding

    Codes table referencedmixed
    No codes listed
    CPT codesCPT
    0358TBioelectrical impedance analysis whole body composition assessment, with interpretation and report.
    76499Unlisted diagnostic radiographic procedure.
    HCPCS / OtherHCPCS
    No code(s)
    DXA-derived thresholds reported in studies
    Whole-body fat mass>25.1 kg (example threshold reported in prospective studies)
    Whole-body fat percentage>41.3% (example threshold reported in prospective studies)
    Trunk fat mass>11.4 kg (example regional threshold reported in prospective studies)
    Serial whole-body fat mass change≥22.1 kg (example serial change cutoff associated with outcomes)
    Serial whole-body fat percentage change≥38.0% (example serial percent-change cutoff reported)
    Serial trunk fat mass change≥9.4 kg (example regional serial change cutoff)
    Waist circumference risk cutoffs
    Waist circumference (men)≥102 cm
    Waist circumference (women)≥88 cm
    ContextCutoffs indicate increased cardiometabolic risk and are recommended for use when BMI and exam are equivocal
    Significant weight loss threshold for DXA reassessment
    Significant weight loss thresholdApproximately >10% weight loss (e.g., post-bariatric or large anticipated weight loss)
    DXA indication contextUsed to assess fat and lean mass changes when weight loss exceeds ~10% per ISCD guidance
    Contraindication notePregnancy is a contraindication to DXA body composition assessment

    The cited chunks reiterate that no explicit 'not medically necessary' statements are provided in those specific sections; coding and administrative instructions are included separately.

    What Providers Must Do / Operational Guidance

    Denial Risk

    Prior approval and coverage headline

    Prior approval: Not applicable. Whole-body DXA and BIA body composition studies are considered investigational for all indications; services may be denied as investigational when submitted without a covered indication.

    • Investigational — potential denial: Claims for whole-body DXA and BIA may be denied because these services are considered investigational for all indications.
    • Benefit verification and contract applicability: Benefit determinations are based on the applicable contract language in effect at the time of service; verify member benefits.
    Documentation Required

    Outpatient whole-body DXA requires confirmation

    When an outpatient whole-body DXA is requested, confirm the test type and that it is being performed in an outpatient setting. Documentation should specify the outpatient setting and the clinical indication.

    • Confirm test type: whole-body DXA body composition study.
    • Confirm setting: outpatient.
    Note

    Evidence insufficiency for clinical utility

    The evidence is insufficient to establish clinical utility for DXA or BIA for body composition assessment because no randomized controlled trials demonstrate that use of these tests to guide management improves patient health outcomes; a chain of evidence cannot be constructed when clinical validity is not established.

    • Direct evidence lacking: no RCTs showing improved health outcomes when care is guided by DXA or BIA results.
    • Chain of evidence: cannot be constructed if clinical validity is insufficient.
    Prior Authorization

    Prior authorization likely for DXA/BIA

    Prior authorization is likely required when DXA or BIA body composition studies are ordered because these modalities lack demonstrated clinical utility and are considered investigational for many indications; submit authorization requests with supporting documentation showing how results will directly influence management.

    • Submit prior authorization when DXA or BIA is requested for body composition assessment that is intended to influence clinical management.
    • Include documentation demonstrating expected impact on management.
    Prior Authorization

    DXA prior authorization when clinically indicated

    DXA may be authorized when clinically indicated — only when the DXA measurement will directly influence a specific clinical decision (for example, evaluation of sarcopenia, cachexia, or monitoring in conditions such as HIV-related lipoatrophy or substantial weight loss after bariatric surgery). Authorization should document the clinical indication and how results will change management.

    • Document that DXA results will directly influence management (e.g., sarcopenia assessment, cachexia, HIV lipoatrophy, bariatric surgery follow-up).
    • Pregnancy is a contraindication to DXA for body composition.
    Billing Rule

    Coding requirement for reporting services

    Use appropriate CPT, HCPCS, Revenue, and/or ICD diagnosis codes when reporting services. Specific CPT codes applicable to body composition services include the bioelectrical impedance analysis code and unlisted radiographic procedure codes as needed.

    • CPT 0358T — Bioelectrical impedance analysis whole body composition assessment, with interpretation and report.
    • CPT 76499 — Unlisted diagnostic radiographic procedure (use when no specific CPT exists).
    • Report appropriate place of service (outpatient/inpatient) and radiology service type.
    Documentation Required

    Evidence requirements for studies

    Study evidence requirements: studies used to evaluate clinical validity must report on the accuracy of the marketed technology (including algorithms), include a suitable reference standard, and describe patient/sample clinical characteristics and selection criteria.

    • Studies must include a suitable reference standard and report accuracy for the marketed version of the test.
    • Describe patient clinical characteristics and selection criteria.
    Denial Risk

    Coverage risk when no demonstrated management impact

    Coverage risk when the test does not demonstrably affect management: tests not shown to change patient management or improve net health outcomes may not meet coverage criteria and are at risk for denial.

    • If DXA or BIA results will not directly influence a management decision that improves net health outcomes, coverage is unlikely.
    Documentation Required

    DXA measurement is indicated only when a

    DXA measurement is indicated only when the result will directly influence clinical decision-making and improve net health outcomes — avoid ordering DXA for body composition without clear documentation of intended management changes.

    • Document specific management decisions that will be made based on DXA results.
    • Avoid routine or research-only use without demonstrated clinical impact.
    Documentation Required

    Study selection and documentation expectations

    Study selection and documentation expectations for prospective studies: prospective cohort studies should report DXA at baseline and follow-up intervals and track outcomes; documentation should include timing of index and reference tests, blinding of assessors when applicable, and clear sample selection methods.

    • Report timing of index and reference tests and blinding of assessors when applicable.
    • Prospective studies should include baseline and serial DXA measurements with outcome follow-up.
    Documentation Required

    Study documentation and follow-up

    Study documentation and follow-up: include long-term follow-up where applicable (for example, serial assessments at standard intervals) and ensure clinical outcomes are confirmed via appropriate methods (medical records, pathology reports, questionnaires as applicable).

    • Document follow-up intervals and methods of outcome confirmation (medical records, pathology reports, validated questionnaires).
    • Ensure sample selection and timing are clearly described.
    Note

    Supporting guideline context

    Supporting guideline context: Guidelines emphasize BMI and waist circumference as first-line screening measures; some specialty guidelines note possible roles for DXA in select populations but highlight limited outcomes data and cost/availability concerns. NICE advises not to use bioimpedance as a substitute for BMI.

    • Consider guideline-recommended screening (BMI, waist circumference) before ordering advanced body composition testing.
    • Specialty guidelines permit DXA in selected clinical scenarios but note uncertain impact on outcomes.
    Documentation Required

    Document clinical indication showing tha

    Document the clinical indication clearly in authorization requests: show that DXA/BIA measurements will directly influence management (e.g., diagnosing sarcopenia, monitoring cachexia treatment, evaluating HIV-associated fat redistribution, or guiding post-bariatric surgery care) and describe how results will change treatment.

    • Provide clinical rationale and specific management actions that will follow from test results.
    • Include relevant clinical history, prior measures (BMI, waist circumference), and planned interventions contingent on results.
    Step Therapy

    Step therapy

    Step therapy: No step therapy requirements are specified in this policy. Providers should consider standard, less costly measures (BMI, waist circumference) before pursuing advanced testing.

    • No formal step therapy required.
    • Consider BMI and waist circumference first; consider less costly measures before DXA/BIA.
    Note

    Consideration of comparators

    Consideration of comparators: before authorizing DXA/BIA, evaluate whether standard of care measures (BMI, waist circumference) or alternative body composition methods are sufficient to address the clinical question.

    • Compare proposed testing to care without DXA and to alternative methods.
    • Document why alternatives are insufficient when seeking authorization.
    Note

    Consideration of alternative methods

    Consideration of alternative methods: consider less costly or more established alternatives (BMI, waist circumference, clinical assessment) before authorizing DXA; do not substitute bioelectrical impedance for BMI per NICE guidance.

    • Use BMI and waist circumference as initial assessments.
    • Do not substitute BIA for BMI as a general adiposity measure.
    Documentation Required

    Requirement for demonstrable management impact

    Requirement for demonstrable management impact: authorization and coverage depend on documentation that test results will inform management decisions expected to improve net health outcomes (correct therapy, more effective therapy, or avoidance of unnecessary interventions).

    • Document specific management changes tied to test results and rationale for how these changes improve outcomes.
    • Without demonstrable impact on management, coverage is unlikely.
    Step Therapy

    Step before advanced testing

    Step before advanced testing: use BMI and waist circumference as initial, lower-cost comparators; consider these measures before authorization of DXA or BIA.

    • Obtain and document BMI and waist circumference prior to considering DXA/BIA.
    • Show why advanced testing is needed beyond these measures.
    Documentation Required

    Consider using BMI and waist circumferen

    Consider using BMI and waist circumference first: guideline-recommended screening should be performed and documented prior to ordering advanced body composition testing; reserve DXA/BIA for situations where these measures are inadequate.

    • Document prior BMI and waist circumference and rationale for insufficiency.
    • Reserve DXA/BIA for conditions where body composition assessment will change management.

    Background and Rationale

    Body composition measurements estimate proportions of fat, lean mass, and bone and can provide more specific information than weight or BMI for certain clinical situations. Techniques reviewed include anthropometrics, bioelectrical impedance analysis (BIA), and dual‑energy x‑ray absorptiometry (DXA); DXA can provide regional and three‑compartment estimates but relies on assumptions that introduce variability across populations.

    Definitions and Key Terms

    DXA (dual-energy x-ray absorptiometry)
    DefinitionDual-energy x-ray absorptiometry (DXA) is an imaging method using two x-ray energies to estimate bone mineral content and soft tissue composition, providing estimates of fat mass, lean mass, and bone mass and regional body composition.
    Regional analysisDXA can determine body composition in defined regions (arms, legs, trunk) and provides three-compartment estimates where applicable.
    AssumptionsDXA-derived soft tissue measures assume constant hydration of fat-free mass (commonly 73%); manufacturers use proprietary algorithms.
    BIA (bioelectrical impedance analysis)
    DefinitionBioelectrical impedance analysis (BIA) measures body impedance via surface or pad electrodes to estimate body composition using device-specific regression models and anthropomorphic inputs.
    Method detailsElectrodes may be attached to arm/foot or the individual may stand on pad electrodes; estimates are affected by hydration, fat distribution, temperature, and other factors.
    Intended useBIA is a noninvasive test intended to assess body composition serially to aid diagnosis and management in certain clinical conditions, though validity is limited in many populations.
    lipodystrophy definition
    DefinitionLipodystrophy: abnormal fat distribution with associated metabolic changes; an outcome of interest particularly for individuals with HIV on antiretroviral therapy.
    Clinical relevanceAssessed with body composition methods (e.g., DXA) when evaluating antiretroviral-associated fat redistribution.
    Outcome examplesIncludes lipoatrophy and central fat accumulation affecting symptom management and metabolic risk.
    intra-abdominal adipose tissue (IAAT)
    DefinitionIntra-abdominal adipose tissue (IAAT) refers to visceral fat quantified by DXA, CT, or MRI.
    Measurement comparatorsDXA IAAT estimates were compared with CT/MRI reference methods in systematic reviews and pooled analyses.
    Clinical contextsIAAT measurement is used to evaluate cardiometabolic risk and central adiposity in research and some clinical scenarios.
    IAAT measures and comparisons
    Pooled correlation (IAAT volume)0.74 (95% CI 0.52 to 0.86) for DXA-derived IAAT volume vs CT/MRI in pooled random-effects analyses
    Pooled correlation (IAAT area)0.71 (95% CI 0.45 to 0.86) reported for IAAT area comparisons
    HeterogeneityHigh heterogeneity reported across analyses (I2 up to 98–99% for some measures), indicating variable agreement between studies.
    Precision error / Coefficient of variation
    Precision error conceptPrecision error reflects the degree to which repeated measurements give the same value; it influences the ability to detect change over time.
    DXA bone mass precisionDXA bone mass precision error is approximately 1%–3% in typical use.
    Fat mass variabilityCoefficients of variation for fat mass by DXA as high as 42.2% have been reported, which can limit clinical validity for some body compartments.
    DXA abbreviation
    AbbreviationDXA = dual-energy x-ray absorptiometry
    UsageCommon shorthand used throughout policy and clinical guidelines.
    ER+ abbreviation
    AbbreviationER+ = estrogen receptor–positive
    ContextUsed in reporting clinical outcomes in some prospective DXA studies (e.g., breast cancer analyses).
    Bioelectrical impedance analysis (BIA) definition
    DefinitionBioelectrical impedance analysis (BIA) is a noninvasive test that assesses body composition serially by measuring electrical impedance and estimating fat and lean mass using device-specific models.
    LimitationsResults can be affected by hydration, fat distribution, ovulation, temperature, and proprietary regression algorithms.
    Intended applicationProposed for serial assessment in diagnostic and management contexts, but validity varies across clinical populations.
    Dual-energy X-Ray absorptiometry (DXA) definition per policy context
    DefinitionDual-energy X-ray absorptiometry (DXA) is an imaging method using two x-ray energies to estimate bone mineral content and soft tissue composition, providing regional and whole-body estimates of fat mass and lean mass.
    Clinical noteACR describes DXA as clinically proven, accurate, and reproducible for BMD and as usable for whole-body composition when results will influence management.
    DXA clinically proven for bone mineral density and whole-body bone but limited for body composition utility per policy
    Clinical utility summaryDXA is clinically proven for bone mineral density and whole-body bone measures, but its utility for body composition to improve patient outcomes is limited/uncertain per policy evidence reviews and guideline statements.
    Guideline contextACR, ASPEN, and ISCD provide recommendations supporting DXA use in select clinical contexts but note uncertain impact on outcomes.
    BIA policy note on limited/uncertain validity in many clinical populations
    Validity concernBIA has limited or uncertain validity in many clinical populations; NICE advises not to substitute bioimpedance for BMI for general adiposity assessment.
    Guideline stanceASPEN made no recommendation supporting BIA validity in clinical populations; evidence quality rated low/very low.
    0358T — Bioelectrical impedance analysis whole body composition assessment code
    CPT code0358T — Bioelectrical impedance analysis whole body composition assessment, with interpretation and report
    Unlisted radiographic code76499 — Unlisted diagnostic radiographic procedure

    Document History

    2013-09original_effective_date

    Policy originally effective (Body Composition policy established).

    2014-08annual_review

    Annual review; policy renewed in August 2014.

    2015-07annual_review

    Annual review with policy revision in July 2015.

    2016-04annual_review

    Annual review with policy revision in April 2016.

    2017-04annual_review

    Annual review; policy renewed in April 2017.

    2018-04annual_review

    Annual review; policy renewed in April 2018.

    2019-04annual_review

    Annual review; policy renewed in April 2019.

    2020-04annual_review

    Annual review with policy revision in April 2020.

    2021-04annual_review

    Annual review; policy renewed in April 2021.

    2022-04annual_review

    Annual review; policy renewed in April 2022.

    2023-04annual_review

    Annual review with policy revision in April 2023.

    2023-11annual_review

    Annual review; policy renewed in November 2023.

    2024-11revision

    Policy revised during the November 2024 annual review.

    2025-11annual_reviewLatest

    Annual review; policy renewed (most recent policy action).