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    OpenPayerPolicy UpdatesRadiology/Diagnostic ImagingCareFirst Bone Density Studies Coverage Update | O…
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    RetiredCareFirstPolicy 6.01.001

    Bone Density Studies

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    Governs coverage and medical necessity criteria for one non-invasive bone density measurement (SPA, DPA, QCT, or DEXA) for CareFirst members, including indications for treatment decision-making, monitoring secondary osteoporosis, and annual monitoring during active osteoporosis therapy.

    Policy Summary
    PayerCareFirst
    PolicyBone Density Studies
    Policy CodePolicy 6.01.001
    Change TypeRetirement / Replaced
    Effective Date10/01/2025
    Last ReviewMay 14, 2025
    Next Review DateMay 14, 2025
    Key ActionRefer to replacement policy 6.01.002 for current prior authorization and coverage rules.
    SourceLink
    POLICY UPDATE CHANGES

    This policy has been retired as of 10/01/2025 and providers are referred to CareFirst medical policy 6.01.002 Bone Density Studies.

    fourtechnologies listed
    onesingle-technology per study
    annualallowed frequency (treated osteoporosis)

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    NCapplicable state

    Coverage and Medical Necessity Criteria

    Bone densitometry to inform estrogen replacement therapy decision

    One bone densitometry using only one of the four listed technologies is considered medically necessary when osteoporosis risk influences decision to initiate estrogen replacement therapy and ALL of the following apply:

    Primary indication for estrogen decision: Patient is perimenopausal considering initiation of estrogen replacement therapy, or is estrogen-deficient after menopause, bilateral oophorectomy, or amenorrhea >= 6 months

    Source: policy indications

    Prior measurement: The patient's bone density has not been previously measured
    Contraindication check: Estrogen replacement therapy is not contraindicated for the patient
    Decisional impact: The individual is undecided about estrogen replacement therapy and knowledge of osteoporosis risk will determine the decision

    Monitoring secondary osteoporosis

    Bone density measurement is medically necessary for monitoring secondary osteoporosis in patients meeting ANY of the following:

    Secondary osteoporosis monitoring: Asymptomatic primary hyperparathyroidism where consideration for surgery is largely determined by bone density; OR patients receiving long-term glucocorticoid therapy where bone density substantiates need for glucocorticoid reduction

    Annual monitoring in treated osteoporosis

    An annual bone density study is considered medically necessary when ALL of the following are met:

    Diagnosis and treatment: Patient has been diagnosed with osteoporosis and is undergoing active treatment with medications that inhibit bone resorption (e.g., calcitonin, bisphosphonates)annual

    Annual frequency specified

    The policy specifies that testing more than one site or using more than one technology during the same session is not supported because it "has not been shown to be more effective than on the hip alone." This single-technology/site approach applies to the listed non-invasive modalities (SPA, DPA, QCT, or DEXA) and underlies the policy’s recommendation to perform only one bone densitometry measurement per evaluation.

    Repeat measurements are not supported when an initial bone density measurement has already been performed. For indications that require an initial measurement (for example, informing a decision about estrogen replacement therapy), the policy requires that the patient's bone density has not been previously measured before the study is considered medically necessary.

    Listed Clinical Indications

    Listed clinical indications for bone densitometry

    Listed clinical indications for bone densitometry include any of the following:

    Indications: Perimenopausal women deciding on estrogen therapy; postmenopausal or estrogen-deficient women (including post‑oophorectomy or amenorrhea >= 6 months); asymptomatic primary hyperparathyroidism when surgery decision depends on bone density; long‑term glucocorticoid therapy monitoring; annual monitoring for patients on antiresorptive therapy

    Allowed Frequency and Technology Use

    Any listed densitometry technology — one initial study allowed
    Allowed initial studyOne bone densitometry study using only one of the four non-invasive technologies (SPA, DPA, QCT, or DEXA) is considered medically necessary for initial evaluation when osteoporosis risk influences the decision to initiate estrogen replacement therapy.
    Applicable populationPerimenopausal women deciding about estrogen replacement therapy, or women estrogen-deficient after menopause, bilateral oophorectomy, or >=6 months amenorrhea.
    Prior measurement requirementPatient's bone density must not have been previously measured.
    Contraindication checkEstrogen replacement therapy must not be contraindicated for the patient.
    Decision impactThe patient must be undecided about estrogen therapy and the bone density result will determine the decision.

    Technologies Referenced (Informational)

    Technologies referenced (informational, not CPT/HCPCS codes)mixed
    SPASingle photon absorptiometry
    DPADual photon absorptiometry
    QCTQuantitative computed tomography
    DEXA/DXA/QDR/DER/DRADual-energy x-ray absorptiometry and synonyms

    Provider Notices and Required Actions

    Note

    Policy retired — refer to replacement policy 6.01.002

    This policy (6.01.001) has been retired as of 10/01/2025; providers must follow the replacement policy CareFirst medical policy 6.01.002 for current guidance and any prior authorization rules.

    Note

    General provider action — use current policy guidance

    Follow the coverage criteria in the active policy (replacement 6.01.002) for ordering and documenting bone densitometry; this retired policy states one non-invasive bone densitometry is considered medically necessary when criteria are met.

    Documentation Required

    Document prior measurement, contraindication, and decisional intent for estrogen therapy

    When ordering bone densitometry to inform an estrogen-replacement decision, document that the patient's bone density has not been previously measured, that estrogen replacement therapy is not contraindicated, and that the test result will determine the patient's decision about estrogen therapy.

    Clinical Background

    Bone densitometry is a non-invasive test that measures bone mineral density to help predict fracture risk and guide clinical decisions. The policy lists four non-invasive technologies in use: SPA (single photon absorptiometry), DPA (dual photon absorptiometry), QCT (quantitative computed tomography), and DEXA (dual-energy x‑ray absorptiometry). These modalities are intended to assess bone density at clinical sites such as the hip and spine and support decisions about initiation of therapy, monitoring secondary causes of bone loss, and annual follow-up during active antiresorptive treatment.

    Definitions of Technologies

    DEXA definition — dual-energy x-ray absorptiometry description
    DefinitionDual-energy x-ray absorptiometry (DEXA) measures bone mineral content and bone mineral density using an x-ray tube source; also known as DER, DRA, QDR, or DXA.
    Technical descriptionA two-dimensional projection system in which an x-ray tube source, rather than a radioisotope, is used as the photon source, providing more accurate and precise readings.
    Sites measuredUsed to measure bone mineral in both peripheral appendicular skeleton and axial skeletal sites, including trabecular and cortical bone.
    QCT definition — quantitative computed tomography description
    DefinitionQuantitative computed tomography (QCT) is a non-invasive method used to assess bone mineral content at both appendicular and axial skeletal sites.
    Unique feature

    Contrast and Modality Notes

    Billing Rule

    Contrast not applicable for bone densitometry modalities

    Contrast rules do not apply. The modalities described (SPA, DPA, QCT, DEXA) are non‑contrast bone densitometry techniques.

    Not Covered / Disallowed Services

    The policy states that multiple-site or multiple-technology testing during the same session is not covered, because testing more than one site in the same encounter "has not been shown to be more effective than on the hip alone." Therefore, performing simultaneous assessments at multiple sites or using multiple densitometry technologies in one session is not supported.

    Policy Status and Revision History

    1998-04-01original_approval

    Original Medical Policy Committee approval of Bone Density Studies (policy 6.01.001).

    2025-05-14last_review

    Policy 6.01.001 was last reviewed by the Medical Policy Committee.

    2025-10-01retired_replacedLatest
    Policy Summary
    PayerCareFirst
    PolicyBone Density Studies
    Policy CodePolicy 6.01.001
    Change TypeRetirement / Replaced
    Effective Date10/01/2025
    Last ReviewMay 14, 2025
    Next Review DateMay 14, 2025
    Key ActionRefer to replacement policy 6.01.002 for current prior authorization and coverage rules.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaListed Clinical IndicationsAllowed Frequency and Technology UseTechnologies Referenced (Informational)Provider Notices and Required ActionsClinical BackgroundDefinitions of TechnologiesContrast and Modality NotesNot Covered / Disallowed ServicesPolicy Status and Revision History
    Any listed densitometry technology — annual monitoring allowed for patients on active osteoporosis therapy
    Allowed frequencyAnnual bone density study is considered medically necessary for patients diagnosed with osteoporosis who are undergoing active treatment with medications that inhibit bone resorption (e.g., calcitonin, bisphosphonates).
    Treatment requirementPatient must have a diagnosis of osteoporosis and be on active antiresorptive therapy.
    Modality flexibilityAnnual monitoring may be performed using any one of the listed non-invasive technologies (SPA, DPA, QCT, or DEXA).
    • Record prior measurement status: “The patient's bone density has not been previously measured.”
    • Record contraindication check: “Estrogen replacement therapy is not contraindicated for the patient.”
    • Record decisional impact: “Knowledge of her risk of osteoporosis would be the determining factor in her decision.”
    Denial Risk

    Single-technology requirement — one technology per evaluation

    Use only one of the four listed non‑invasive technologies (SPA, DPA, QCT, or DEXA) for a single evaluation; testing on more than one site or using multiple technologies in the same session is discouraged and not supported.

    • Allow one bone densitometry using a single technology per evaluation (SPA, DPA, QCT, or DEXA).
    • Do not perform multiple-site or multiple-technology testing during the same session; it has not been shown to be more effective than hip testing alone.
    Prior Authorization

    Prior authorization — see replacement policy 6.01.002

    This retired policy directs providers to the replacement policy (6.01.002) for current prior authorization requirements; prior authorization rules are governed by 6.01.002 rather than this document.

    QCT is the only non-invasive method described that assesses bone mineral content at both appendicular and axial sites.

    Policy 6.01.001 was retired and providers were referred to replacement policy 6.01.002 (Bone Density Studies).