Bone Density Testing (DXA and related modalities) — Coverage Criteria
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Defines coverage, limitations, and non-covered bone density testing services for West Virginia Medicaid members, and outlines prior authorization and documentation requirements for providers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered services with limitations
Covered when medically necessary and ordered by the treating provider; the following rules apply:
Supported by chunk 3
Supported by chunk 3
Supported by chunk 3
Supported by chunk 3
The following bone density testing services are explicitly listed as non-covered when used for routine screening in members without risk factors: routine screening for members without risk factors. This exclusion is stated under Non-Covered Services and applies to services that do not meet medical necessity criteria for screening.
Additionally, the policy specifies that photodensitometry of peripheral bones (for example wrist, finger, heel) and ultrasound bone densitometry used for monitoring osteoporosis are not allowed as part of monitoring. These modalities are identified separately from axial DXA and are listed among non-covered procedures.
Routine population screening in members who do not have risk factors for osteoporosis is listed as a non-covered service: Routine screening for members without risk factors. Requests for such screening should not be submitted for coverage as they do not meet the policy's medical necessity criteria.
Diagnosis and Monitoring Indications
Diagnosis and monitoring of osteoporosis
Supported by chunks 3 and 6
Coding and Frequency Limits
| No codes listed |
Frequency and Billing Rules
Prior Authorization Requirements
Prior authorization required for more-frequent testing and UMC-designated services
Prior authorization is required from the Utilization Management Contractor (UMC) for bone density tests requested more frequently than once every two years; the request must include documentation of medical necessity. Additionally, prior authorization is required for radiology services designated by the utilization management contractor and must be obtained before the service is rendered except when medically necessary during an emergent ER visit. A referring/treating provider must order all covered services.
- Requests for testing more often than once every two years require UMC prior authorization with documentation of medical necessity.
- Prior authorization must be obtained before the service is rendered when required by the UMC (except emergent ER visits).
- A referring/treating provider must order all covered bone density services.
Non‑covered monitoring modalities — denial risk
Use of peripheral photodensitometry or ultrasound bone densitometry for monitoring osteoporosis is not allowed and may be denied; only axial testing (e.g., hip and spine) is permitted for monitoring. Requests that use non‑covered modalities for monitoring are at risk for denial.
- Only axial testing (hip and spine) is allowed for monitoring osteoporosis therapy.
- Photodensitometry of peripheral bones (wrist, finger, heel) and ultrasound bone densitometry are not allowed for monitoring and may be denied.
Provider Orders, Documentation, and Denial Risks
Order all covered services and obtain prior authorization when required
A referring or treating provider must order all covered bone density services; if prior authorization is required for the service, it must be obtained before the service is rendered except in emergent emergency room visits.
Frequency exceptions require prior authorization with medical documentation
Requests for bone density testing that are more frequent than once every two years require prior authorization and must include documentation demonstrating medical necessity for the shortened interval.
- Policy limit: testing is limited to once every two years; exceptions require UMC prior authorization.
- Submit supporting clinical documentation with the prior authorization request.
Include separate written interpretation in the member's chart
When the imaging provider is also the treating practitioner, include a separate written interpretation of the bone density scan in the member's medical chart.
Non‑covered monitoring modalities may be denied
Peripheral photodensitometry and ultrasound bone densitometry are non‑covered for monitoring osteoporosis and use of these modalities may result in denial of the claim.
- Photodensitometry of peripheral bones (wrist, finger, heel) is not allowed for monitoring.
- Ultrasound bone densitometry is not allowed for monitoring.
Use axial testing only for monitoring; avoid non‑covered modalities
Follow the policy requirement that only axial testing (e.g., hip and spine) is allowed for monitoring osteoporosis; ensure orders and documentation reflect axial modality selection and avoid billing for non‑covered peripheral or ultrasound monitoring studies.
Non-Covered Services
Photodensitometry of peripheral bones and ultrasound bone densitometry used for monitoring osteoporosis are explicitly non-covered. The policy states that photodensitometry of a peripheral bone (e.g., wrist, finger, heel) and ultrasound bone densitometry are not allowed as part of monitoring, and lists these modalities under non-covered services.
These non-covered modalities may be subject to denial when submitted for the purpose of monitoring osteoporosis and are distinct from axial DXA testing, which is the preferred modality for diagnosis and monitoring when medically necessary.
Definitions
Background
Bone density testing (also called bone mass measurement) is used to identify members with osteoporosis and to monitor response to osteoporosis treatment. Osteoporosis is characterized by low bone mass, deterioration of bone tissue, compromised bone strength, and increased fracture risk. Axial DXA (hip and spine) is frequently used for initial screening and baseline measurement because of its reproducibility and diagnostic capability. The overall goal of testing is to reduce fracture risk by informing diagnosis and treatment decisions.
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