CurrentUCarePolicy CP-IFP20-032A

Bone Mineral Density Studies

Defines coverage and methods for measuring bone mineral density for UCare Individual & Family Plans and specifies products to which the policy applies.

Policy Summary

PayerUCare

PolicyBone Mineral Density Studies

Policy CodePolicy CP-IFP20-032A

Change TypeNo material change

Effective DateOctober 1, 2022

Next Review Date

Key ActionDo not submit prior authorization requests for bone mineral density studies; prior authorization is not required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3+Covered methods listed

6Codes listed

Not requiredPrior auth

65+Screening age

Coverage Criteria for Bone Mineral Density Studies

Coverage and indications

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Covered methods: Examples of covered methods include: Single energy x-ray absorptiometry (SEXA); Dual energy x-ray absorptiometry (DXA or DEXA); Quantitative computed tomography (QCT); other methods such as bone ultrasound densitometry, photo densitometry, and radiographic absorptiometry

From list of covered methods and benefit category

Preventive screening: Screening is indicated for women aged 65 and older; postmenopausal women younger than 65 years at increased risk as determined by clinical risk assessment; targeted screening in select men at significant risk of osteoporosis

Preventive screening guidance

Other diagnostic indications: Bone mineral density studies may be used to diagnose osteoporosis, monitor disease progression, or monitor response to therapy

Clinical uses and anatomic sites include spine, hip, lower arm/wrist, fingers, and heel

Tests performed in individuals who do not have risk factors or a history of fractures may be billed and adjudicated under other benefit categories rather than as routine diagnostic bone mineral density studies. Examples called out in the policy include persons without risk factors or prior fractures and persons taking long‑term medications associated with secondary osteoporosis; these services may be subject to different coverage rules depending on the member’s plan and benefit category.

The policy notes that testing in individuals without risk factors or a history of fractures may be payable under other benefit categories. Providers should confirm member plan benefits and submit claims under the appropriate benefit category when screening or testing is performed in asymptomatic individuals without defined risk factors or prior fracture history.

Osteoporosis Diagnosis, Monitoring, and Screening Indications

Osteoporosis diagnosis and monitoring; screening in specified populations

Covered indications for osteoporosis diagnosis, monitoring, and targeted screening

Clinical indications: Diagnose osteoporosis; monitor response to osteoporosis treatment; assess fracture risk in individuals with risk factors (eg, low BMI, excessive alcohol consumption, current smoking, long-term corticosteroid use, history of prior fractures, history of falls within the past year); evaluate secondary causes of osteoporosis or conditions increasing fall risk

Includes targeted testing for persons taking long-term medications that may cause secondary osteoporosis (eg, glucocorticoids, aromatase inhibitors, GnRH agonists)

Procedure Codes and Preventive Screening

Listed procedure codesCPT

76977	Ultrasound bone density measurement and interpretation, peripheral site(s), any method.
77078	Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine).
77080	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine).
77081	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel).
77085	Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment.
G0130	Single energy x-ray absorptiometry (SEXA) bone density study, 1 or more sites, appendicular skeleton (peripheral) (eg, radius, wrist, heel).

Preventive screening age — Women aged 65 and older

Preventive screening ageWomen aged 65 and older

Younger postmenopausal womenPostmenopausal women younger than 65 at increased risk as determined by clinical risk assessment tool

Select menTargeted screening in select men at significant risk of osteoporosis

Provider Actions and Billing Rules

Prior Authorization

Prior authorization: Prior authorization is not required for bone mineral density studies.

Applies to DXA and other bone mineral density studies.
Policy Number: CP-IFP20-032A; Original Effective Date: October 1, 2022

Note

Documentation Required

Provider Responsibility

Provider responsibility: Providers are responsible for submission of accurate and compliant claims. Refer members to their UCare plan documents (Evidence of Coverage/Member Handbook/Member Contract) for specific coverage details. If a conflict exists between a coverage policy and a UCare plan document, the plan document prevails.

Billing Rule

Diagnostic Services Billing

Diagnostic services related to bone density testing may be payable under other benefit categories. Examples include tests in individuals without risk factors or a history of fractures; persons on long-term medications that may cause secondary osteoporosis (eg, glucocorticoids, aromatase inhibitors, or gonadotropin-releasing hormone agonists); persons with medical conditions that increase fall risk; testing for secondary osteoporosis due to metabolic bone disease or untreated hyperthyroidism; and monitoring response to osteoporosis treatments.

Tests in individuals without risk factors or a history of fractures
Persons on long-term medications that may cause secondary osteoporosis (eg, glucocorticoids, aromatase inhibitors, gonadotropin-releasing hormone agonists)
Persons with medical conditions that may increase risk of falls
Testing for secondary osteoporosis due to metabolic bone disease or untreated hyperthyroidism
Monitoring response to treatments for osteoporosis

Prior Authorization Requirements

Prior Authorization

All listed modalities — no prior auth

Prior authorization is not required for any of the listed bone mineral density modalities (DXA, QCT, SEXA, ultrasound) or CPT/HCPCS codes.

Covered example methods include Single energy x-ray absorptiometry (SEXA), Dual energy x-ray absorptiometry (DXA), and Quantitative computed tomography (QCT).
Policy statement: Prior authorization — Not required.

Definitions

Bone mineral density study — definition and purpose

DefinitionBone (mineral) density studies measure the amount of calcium and other minerals in bone to evaluate bone disease, monitor progression, or monitor response to therapy.

Purpose — diagnoseUsed to diagnose osteoporosis and other bone disease.

Purpose — monitor progressionUsed to monitor the course of bone changes with disease progression.

Purpose — monitor therapy responseUsed to monitor how well osteoporosis treatments are working.

Common sitesLower spine, hip, lower arm, wrist, fingers, and heel.

Background

Bone mineral density studies are used to evaluate bone health, diagnose osteoporosis, monitor disease progression, and assess response to therapy. The policy indicates that certain diagnostic services — including testing to evaluate secondary causes of osteoporosis, monitoring response to osteoporosis treatment, and evaluation of persons at increased fall risk or on long‑term osteoporosis‑inducing medications — may be performed as part of care that is categorized under diagnostic benefit categories.

Not Covered

The policy does not list any specific modality/indication combinations that are explicitly not covered. Instead, it advises that some diagnostic services and tests performed in persons without risk factors or a history of fractures may be payable under other benefit categories, implying that lack of coverage in one category does not necessarily mean the service is not payable under another.