CurrentHighmark DelawarePolicy N/A

Bone density (DEXA) scan authorization and information

Form and instructions used by Highmark Delaware to collect clinical information and determine medical necessity/authorization requirements for bone density scans (DEXA) for members; affects ordering providers and members across Highmark Delaware lines of business.

Policy Summary

PayerHighmark Delaware

PolicyBone density (DEXA) scan authorization and information

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and fax the Bone Density Information Form with required clinical details to Highmark Delaware Medical Management for authorization or medical review as specified by member age and plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Women ≥45Women exempt from auth

Men any age & women <45Auth required (IPA/POS)

EPO/PPO/TraditionalClaims reviewed

FaxSubmission

Coverage and Authorization Criteria

Authorization and review criteria by age and plan

Coverage/authorization rules based on age and plan type

Women 45 and older: Women 45 years and older do not require authorizations or medical review for any lines of business.age >= 45

No authorization or medical review required

Men and women under 45 with IPA/POS: Men of any age and women younger than 45 years require authorization for members with IPA/POS coverage.men:any age OR women<45 AND plan=IPA/POS

Authorization required

EPO/PPO/Traditional plans: For EPO/PPO/Traditional members, claims are reviewed for medical necessity (authorization not explicitly required).

Policy Summary

PayerHighmark Delaware

PolicyBone density (DEXA) scan authorization and information

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for men of any age and for women younger than 45 years who have IPA/POS coverage. EPO, PPO, and Traditional members' claims are reviewed for medical necessity (authorizations not required for these lines of business). Women 45 years and older do not require authorization or medical review for any line of business.

Men of any age — authorization required (IPA/POS).
Women <45 years — authorization required (IPA/POS); EPO/PPO/Traditional: claims reviewed for medical necessity.
Women ≥45 years — no authorization or medical review required for any line of business.

Denial Risk

Authorization Requirement Triggers Denial

Failure to obtain required authorization for men of any age and for women younger than 45 years with IPA/POS coverage may result in denial of the claim.

Authorization triggers denial risk when not obtained for IPA/POS members in the affected groups.

Documentation Required

Required Documentation to Determine Medical Necessity

Providers must complete and fax the Bone Density Information Form with patient demographics and relevant clinical history to determine medical necessity. The form collects menopausal status, hormone replacement therapy, osteoporosis medication, long-term steroid use, thyroid disease, prior osteopenia on X‑ray, fracture history, and date of last bone density scan.

Fax completed form to Highmark Delaware Medical Management at 302.421.8864 or 800.670.4862.
Form must include: patient demographics, date of service, physician contact, menopausal status, medications, steroid use, thyroid disease, prior osteopenia, fracture history, and prior bone density scan date.

Field Definitions and Risk Factors

Long term steroid therapy

DefinitionLong term steroid therapy — checkbox on the Bone Density Information Form indicating chronic glucocorticoid exposure as a risk factor for decreased bone density.

Form locationCaptured in the patient history section: 'Has the patient been on long term steroid therapy?' with Yes/No checkbox.

Clinical relevanceUsed to identify patients at increased risk for osteopenia/osteoporosis and to support medical necessity for bone density (DEXA) scanning.

Documentation requirementProviders must complete the form (including this checkbox) and fax it to Highmark Delaware Medical Management to support authorization/medical necessity determinations.

Associated itemsCollected alongside other risk factors on the form: menopausal status, hormone replacement, osteoporosis medication, thyroid disease, prior radiographic osteopenia, fracture history.

Date of last bone density scan

DefinitionDate of last bone density scan — date field on the Bone Density Information Form used to record the most recent DEXA study.

Form locationCaptured in the patient information section as 'Date of last bone density scan' with a date entry field.

PurposeAssesses the interval between studies to determine the need for repeat bone density scanning and to support medical necessity review.

Documentation requirementProviders must include this date when faxing the completed form to Highmark Delaware Medical Management for authorization or medical necessity review.

Related dataUsed in conjunction with clinical risk factors (steroid use, menopausal status, osteoporosis treatment, fracture history) to inform review decisions.

OpenPayer

Bone density (DEXA) scan authorization and information

Coverage and Authorization Criteria

Provider Requirements and Prior Authorization

Clinical Background

Field Definitions and Risk Factors