Currentblue cross blue shield - tennesseePolicy N/A

Bone_Turnover_Markers_Testing_Reimbursement_Policy

Defines coverage positions for measurement of biochemical bone turnover markers (formation and resorption markers) for osteoporosis and other bone conditions, including indications that meet or do not meet coverage and reimbursement policy notes about other conditions and assay types.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyBone_Turnover_Markers_Testing_Reimbursement_Policy

Policy CodePolicy N/A

Change TypeAdoption of Avalon recommendation

Effective Date7/1/2023

Next Review DateN/A

Key ActionVerify member benefit coverage and document the indication when ordering BTMs to support one of the covered uses.

SourceLink

POLICY UPDATE CHANGES

Adopted Avalon policy recommendation effective 7/1/2023.

3Covered indications (osteoporosis initial evaluation, fracture risk prediction, bisphosphonate adherence)

3Not covered uses (monitor teriparatide, diagnostic for osteoporosis, other high-turnover conditions)

6Preferred markers referenced (PINP, CTX, BSAP, NTX, OC, TRACP5b)

multipleCited sources

Scope: This policy defines coverage positions for measurement of biochemical bone turnover markers (BTMs) — both formation and resorption markers — in the evaluation and management of osteoporosis and related situations. It specifies covered and not-covered uses, and includes notes about assay types and regulatory considerations.

Coverage stance: Mixed — certain uses are covered while others are not. Status: CURRENT (policy adoption effective 7/1/2023).

Covered indications (3 total): measurement of BTMs meets coverage criteria for (1) initial evaluation and management of osteoporosis, (2) fracture risk prediction in osteoporosis patients, and (3) assessment of adherence to bisphosphonate therapy in treated individuals. Not-covered uses (3 total): measurement of BTMs does not meet coverage criteria to monitor teriparatide treatment, as a diagnostic test for osteoporosis, or for diagnosis/management of other high-turnover conditions (e.g., Paget's disease, primary hyperparathyroidism, renal osteodystrophy).

Key thresholds and quick facts

Least Significant Change (LSC)Varies by assay; examples from Eastell et al. 2000: 31% decrease for urinary NTX and 14% decrease for serum NTX required to be 90% confident a change exceeds variability.

Example BSAP cutoff (study)Study (Mederle et al., 2018) reported BSAP cutoff 21.27 U/L (sensitivity 76.5%, specificity 84.3%).

Example TRAP-5b cutoff (study)Study (Mederle et al., 2018) reported TRAP-5b cutoff 3.45 U/L (sensitivity 86.3%, specificity 90.6%).

Preferred markers (clinical guidelines)Guidelines and consensus groups identify PINP (formation) and CTX (resorption) as preferred markers for fracture risk prediction and monitoring (IOF/IFCC, AACE/ACE, ESCEO consensus).

Effective datePolicy adoption effective 7/1/2023 (Adopted Avalon policy recommendation).

OpenPayer

Bone_Turnover_Markers_Testing_Reimbursement_Policy

Coverage Summary