Bone mineral density (BMD) measurement is a non-invasive technique that is used to measure bone mineral content and bone mineral density. Its primary role is to detect osteoporosis and to predict the risk of fractures. Dual-energy absorptiometry (DEXA) is the most commonly used technique to measure BMD. Lateral spine images can also be obtained using DEXA, and thus is it possible to screen for vertebral fractures at the same time a subject is undergoing assessment of bone mineral density. This guideline addresses central bone mineral density measurements and vertebral fracture assessment using dual energy X-Ray absorptiometry.

Note(s): 
For information regarding peripheral (e.g. forearm, finger, and heel) bone density studies including the use of heel densitometry, peripheral dual energy x-ray absorptiometry (pDEXA), radiographic absorptiometry of the fingers, single energy X-ray absorptiometry (SEXA), single photon absorptiometry (SPA), and dual X-ray and laser (DXL), please refer to RAD.00004 – Peripheral Bone Mineral Density Measurement. 

This document does not address bone density testing by computed tomography.

Medically Necessary:

INITIAL CENTRAL BONE MINERAL DENSITY MEASUREMENTS
In general, a baseline central bone mineral density (BMD) measurement may be considered medically necessary whenever there is a reasonable expectation that the findings will be abnormal and a treatment decision may be influenced by the outcome of the test.

Specifically, an initial (baseline) central (hip or spine) bone density measurement is considered medically necessary when performed in any of the following settings:

1. An initial examination in menopausal or post-menopausal women to screen for osteoporosis.  No additional criteria are required.
2. Individuals (male or female) with clinical evidence of vertebral osteoporosis as indicated by any of the following:
   • Decrease in height of greater than 1.5 inches; or
   • Presence of kyphosis; or
   • X-ray identification of vertebral compression fractures, osteoporosis, or osteopenia (low bone mass).
3. Individuals who are known or suspected to have a condition that may underlie the osteoporosis, including but not limited to the following:
   • Anorexia nervosa; or
   • Calcitonin deficiency; or
   • Chemotherapeutic agents which affect bone density; or
   • Chronic liver disease; or
   • Chronic renal failure; or
   • Chronic use of anti-convulsants (particularly Dilantin); or
   • Chronic use of heparin; or
   • Cushing's Syndrome (hypercortisolism); or
   • Fragility or pathologic fracture; or
   • Hypersecretion of calcitonin; or
   • Hypercalciuria; or
   • Hyperthyroidism; or
   • Hypothyroidism; or
   • Hypogonadism; or
   • Inflammatory bowel disease; or
   • Lupron therapy in men; or
   • Malabsorption syndromes; or
   • Malignancies (multiple myeloma); or
   • Organ transplantation; or
   • Osteogenesis imperfecta; or
   • Prolonged amenorrhea (6 months duration or longer); or
   • Prolonged immobilization; or
   • Radiologic evidence of osteopenia; or
   • Receiving aromatase inhibitor therapy;
   • Receiving long-term glucocorticoid therapy (greater than three months or the equivalent dose of 7.5 mg prednisone [or 30 mg cortisone] or more per day), provided intervention is an option; or
   • Rheumatoid arthritis; or
   • Untreated premature menopause; or
   • Vertebral abnormalities.

REPEAT CENTRAL BONE MINERAL DENSITY MEASUREMENTS 

Individuals Not On Therapy Related To Osteoporosis:

1. For those without significant osteopenia or not at high risk for accelerated bone loss, repeat testing is considered medically necessary every 3 to 5 years.
2. For individuals with significant osteopenia or at high risk for accelerated bone loss including individuals with any one of the conditions listed in number three (3) above, repeat measurement is considered medically necessary every 2 to 3 years.
3. Individuals who have an initial BMD measurement well above the minimal desirable level may not need a repeat measurement.

Individuals On Therapy Related To Osteoporosis:

Repeat measurements of BMD as a technique to monitor response to therapy for osteoporosis are considered medically necessary when performed at intervals of 2 years or greater. 

CENTRAL BONE DENSITY MEASUREMENTS for Asymptomatic Hyperparathyroidism

Bone density measurement using the spine (trabecular bone), or hip (mixed cortical and trabecular bone) is considered medically necessary when performed for individuals (male or female) with asymptomatic primary hyperparathyroidism (PHPT) where consideration for surgery is in large part determined by bone density level.

Not Medically Necessary:

CENTRAL BONE DENSITY MEASUREMENTS
Central bone density measurement is considered not medically necessary in any of the following circumstances:

1. Routine screening for osteoporosis or osteoporosis risk for individuals who do not meet the criteria above.
2. Individuals starting hormone therapy for treatment of menopausal symptoms or who are being monitored for effects of hormone therapy prescribed for menopausal symptoms and who do not meet the criteria above.
3. Monitoring therapy response in individuals on therapy related to osteoporosis at intervals of less than 2 years.

VERTEBRAL FRACTURES USING DUAL X-RAY ABSORPTIOMETRY
Screening for vertebral fractures using dual x-ray absorptiometry as an adjunct to bone mineral density measurement is considered not medically necessary.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

Description of Disease
Osteoporosis is characterized by slow, prolonged bone loss. The National Osteoporosis Foundation in 2004 noted that in the United States 10 million individuals are estimated to have osteoporosis, including 55 percent of people age 50 years and older. The disease is four times more likely to occur in women than in men. In addition, almost 34 million more are estimated to have low bone mass (i.e. osteopenia), placing them at increased risk for osteoporosis. About 1.5 million fractures annually are due to osteoporosis. These fractures are most common at the hip, spine, and wrist and can result in serious morbidity and in some cases death. The incidence of osteoporosis in the U.S. is expected to increase significantly in the future as the population ages. 

Treatment of Disease
The goal of osteoporosis treatment is to prevent or decrease the rate of bone loss.  Such treatment may include, but is not necessarily limited to calcium and vitamin supplementations, exercise and medications such as calcitonin, parathyroid hormone, estrogens, bisphosphonates (alendronate, ibandronate and risedronate), and raloxifene.

Treatment planning represents a joint decision by the individual and their treating physician following discussion of the potential risks and benefits of therapy.

Description of Technology
Bone densitometry is a non-invasive technique that is used to measure bone mineral content in order to predict fracture risks and need for medical therapy. BMD can be measured at several anatomical locations. Peripheral BMD are generally determined by obtaining measurements at the wrist, forearm, finger or heel, while central BMD measurements are obtained by obtaining measurements from the hip or spine. Bone mineral density (BMD) is typically expressed as the T-score (e.g., the number of standard deviations [SD] below the mean for non-osteopenic, healthy, young women). The World Health Organization defines osteopenia as a T-score of between –1.0 and -2.5 SD, and osteoporosis as a score of –2.5 SD or more.

Initial and Repeat Bone Mineral Density Measurements
There is adequate evidence to support the use of central bone density studies to assess the risk of osteoporosis in settings where the results may influence medical therapy. Studies have demonstrated the efficacy of bone mineral studies for several populations at higher risk for this process, including postmenopausal women, especially those over the age of 65, individuals currently receiving medications for osteoporosis prophylaxis, those receiving glucocorticoid therapy and individuals with endocrinopathies or other conditions which predispose to osteoporosis.  Examples of these include: hyperthyroidism and hypothyroidism, hyperparathyroidism, corticosteroid use, and rheumatoid arthritis.  Currently both the American Association of Clinical Endocrinologist Medical Guidelines for Clinical Practice for the Prevention and Treatment of Postmenopausal Osteoporosis (2001 edition, with selected updates for 2003) and the U.S. Preventative Services Task Force statement on Screening for Osteoporosis in Postmenopausal Women recommend a screening BMD scan for all women over the age of 65 (USPHTF B recommendation).  The American College of Obstetricians and Gynecologists recommends screening for all postmenopausal women who have sustained a fracture and for all postmenopausal women with any of a broadly defined set of risk factors.

The timing of additional studies after the initial screening is a topic of discussion. The use of bone density studies more frequently than every 23 months is not recommended by the American College of Obstetrics and Gynecology. This is based upon the results of several trials that evaluated the change in bone mineral density in individuals undergoing therapy for various conditions. These studies found that change in bone density could not be meaningfully assessed until late in the second year of therapy because some individuals actually continue to lose bone density during the first year but have subsequent significant increases during the second year of therapy.  Alternatively, the American Association of Clinical Endocrinologists notes that until evidence-based specific data is available for BMD monitoring, they recommend bone density studies for individuals undergoing osteoporosis prevention, every 1 to 2 years until bone mass is stable, then every 2-3 years after stabilization.  In addition, the AACE recommends when monitoring therapy, bone studies be done yearly for two years, and if bone mass is stabilized then every 2 years thereafter, if not stabilized, then yearly until bone mass is stabilized.

Screening for Vertebral Fractures Using DEXA
Studies have investigated the use of DEXA as a screening tool for vertebral fractures as an adjunct to bone mineral density (BMD) measurements in asymptomatic individuals. These studies have reported that asymptomatic vertebral fractures may be present in up to 20% of postmenopausal women who have normal BMD measurements. However, it is not known whether any specific therapy, i.e., bisphosphonate therapy, will reduce fracture risk in these individuals with normal bone mass.

Studies comparing DEXA vertebral fracture assessment to lateral spine X-rays (considered the "gold standard" for diagnosis of vertebral fractures) have shown high levels of agreement between the two techniques. If this were the only issue, there would be little debate as to the suitability of using DEXA for this purpose. However, one basic principle of screening is that there must be clear treatment guidelines demonstrating improvement in health outcomes related to treatment of an asymptomatic condition.  Currently treatment of osteoporosis is based on the presence of a decreased BMD.  At this time, there is no clear guidance for the treatment of an asymptomatic vertebral fracture in women with a normal BMD.  For example, it is not known whether anti-resorptive therapy would improve the fracture risk in individuals with normal or near-normal bone mineral density.

Peer Reviewed Publications:

1. Blake GM, Fogelman I. Peripheral or central densitometry: does it matter which technique we use? J Clin Densitom. 2001; 4(2):83-96.
2. Chappard C, Roux C, et al. Bone status in primary hyperparathyroidism assessed by regional bone mineral density from the whole body scan and QUS imaging at calcaneus. Joint Bone Spine 2006; 73(1):86-94.
3. Cummings SR, Bates D, Black DM. Clinical use of bone densitometry: scientific review. JAMA. 2002; 288(22):1889-1897.
4. Deal CL. Using bone densitometry to monitor therapy in treating osteoporosis: pros and cons. Curr Rheumatol Rep. 2001; 3(3): 233-239.
5. Ferrar L, Jiang G, Eastell R, Peel NF. Visual identification of vertebral fractures in osteoporosis using morphometric x-ray absorptiometry. J Bone Min Res 2003; 18(5):933-938.
6. Greenspan SL, von Stetten E, Emond SK, et al. Instant vertebral assessment: a noninvasive dual X-ray absorptiometry technique to avoid misclassification and clinical mismanagement of osteoporosis. J Clin Densitometry. 2001; 4(4):373-380.
7. Johnell O, Kanis JA, Oden A, et al. Predictive value of BMD for hip and other fractures. J Bone Miner Res. 2005; 20(7):1185-1194.
8. Liu H, Paige NM, Goldzweig CL, et al. Screening for osteoporosis in men: a systematic review for an American College of Physicians guideline. Ann Intern Med. 2008; 148(9):685-701.
9. Miller PD, Zapalowski C, Kulak CA, et al. Bone densitometry: the best way to detect osteoporosis and to monitor therapy. J Clin Endocrinol Metab. 1999; 84(6):1867-1871.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Association of Clinical Endocrinologists (AACE) and American Association of Endocrine Surgeons (AAES) position statement on the diagnosis and management of primary hyperparathyroidism. AACE/AAES Task Force on Primary Hyperparathyroidism. Am J Gastroenterol. 2005; 11(1):49-54. Available at: https://www.aace.com/sites/default/files/HyperparathyroidPS.pdf. Accessed on September 23, 2011.
2. American Association of Clinical Endocrinologists (AACE). Medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract. 2010; 16(Supl 3):1-37. Available at: https://www.aace.com/sites/default/files/menopause.pdf.  Accessed on September 21, 2011.
3. American Association of Clinical Endocrinologists (AACE). Medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 Edition, with Selected Updates for 2003. Endocr Pract. 2003; 9(6):544-564.
4. American College of Obstetrics and Gynecology. Committee Opinion No. 270. Bone density screening for osteoporosis. Obs Gynecol. 2002; 99(3):523-525.
5. American College of Obstetrics and Gynecology. Committee Opinion No. 407. Low bone mass (osteopenia) and fracture risk. Obstet Gynecol. 2008; 111(5):1259-1261.
6. American College of Obstetrics and Gynecology. Committee Opinion No. 415. Depot medroxyprogesterone acetate and bone effects. Obstet Gynecol. 2008; 112(3):727-730.
7. Blue Cross and Blue Shield Association. Screening for vertebral fracture with dual x-ray absorptiometry. TEC Assessment, 2005; 20(14).
8. Centers for Medicare and Medicaid Services. National Coverage Determination for Bone (Mineral) Density Studies. NCD #150.3. Effective July 1, 1998. Available at: http://www.cms.hhs.gov . Accessed on September 23, 2011.
9. National Institute of Health (NIH). Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Statement. 2000; 17(1):1-45. Available at: http://consensus.nih.gov/2000/2000Osteoporosis111html.htm.  Accessed on September 23, 2011.
10. National Osteoporosis Foundation. Clinician's guide to prevention and treatment of osteoporosis.  Revised January 2010. Available at: http://www.nof.org/sites/default/files/pdfs/NOF_ClinicianGuide2009_v7.pdf. . Accessed on September 23, 2011.
11. Qaseem A, Snow V, Shekelle P, et al. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008; 148(9):680-684.
12. U.S. Preventive Services Task Force (USPSTF). Screening for Osteoporosis in Postmenopausal Women. a review of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2002; 137(6):529-541. Available at: http://www.annals.org/content/137/6/529.full.  Accessed on September 23, 2011.

Bone Mineral Density Measurement
DEXA, Screening for Vertebral Fractures Using
Dual X-Ray Absorptiometry, Screening for Vertebral Fractures Using
Fractures (Vertebral), Screening for Using Dual X-Ray Absorptiometry
Instant Vertebral Assessment (IVA)
Lateral Vertebral Assessment (LVA)
Osteoporosis
Screening for Vertebral Fractures Using Dual X-Ray Absorptiometry
Vertebral Fractures, Screening for Using Dual X-Ray Absorptiometry