DEXA bone scan criteria for the Federal Employee Program®

Osteoporosis affects more than 50 million Americans. Treatment options are better and bone fractures are more preventable the sooner it is detected.  Does your patient meet the criteria for a DEXA bone scan? Initial or repeat bone mineral density (BMD) measurement is not indicated unless the results will influence treatment decisions.

To assist providers in administrative requirements for bone mineral density (BMD) studies, the Federal Employee Program (FEP®) medical policy and utilization guidelines can be found on fepblue.org.  The medical policy is titled, Medical Policy MPM 6.01.01, Bone Mineral Density Studies.  Below is an outline of this policy.   

Policy Statement:

An initial measurement of central (hip/spine) BMD using dual x-ray absorptiometry (DXA) may be considered medically necessary to assess future fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis.

BMD testing may be indicated under the following conditions:

• Women age 65 and older, independent of other risk factors
• Men age 70 and older, independent of other risk factors
• Younger postmenopausal women with an elevated risk factor assessment (see policy guidelines)
• Men age 50 to 70 with an elevated risk factor assessment (see policy guidelines)
• Adults with a pathologic condition associated with low bone mass or increased bone loss
• Adults taking a medication associated with increased bone loss

 

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry for individuals who previously tested normal may be considered medically necessary at an interval not more frequent than every 3 to 5 years; the interval depends on an updated patient fracture risk assessment.

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-2 years as follows:

• Individuals with a baseline evaluation of osteopenia (BMD T- score -1.0 to -2.5)
• Adults with a pathologic condition associated with low bone mass or increased bone loss
• Adults taking a medication associated with increased bone loss

 

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-3 years in individuals who are receiving pharmacologic treatment for osteoporosis when the information will affect treatment decisions (continuation, change in drug therapy, cessation or resumption of drug therapy).

Peripheral (lower arm, wrist, finger or heel) BMD testing may be considered medically necessary when conventional central (hip/spine) DXA screening is not feasible or in the management of hyperparathyroidism, where peripheral DXA at the forearm (i.e., radius) is essential for evaluation.

Dual x-ray absorptiometry of peripheral sites is considered investigational except as noted above.

BMD measurement using ultrasound densitometry is considered not medically necessary.

BMD measurement using quantitative computed tomography is considered investigational.

If you have any questions about Federal Employee benefits or medical policy information, please contact Customer Service at 800-282-2473.

 

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