Vertebral Fracture Assessment or Biomechanical Computed Tomography Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 10|01|2015 POLICY LAST REVIEWED: 09|16|2025 OVERVIEW Vertebral fracture assessment (VFA) with densitometry is a technique to assess vertebral fractures at the same time as bone mineral density, using additional software with dual-energy x-ray absorptiometry. The addition of VFA to bone mineral density may augment diagnostic information on fracture risk. Another method of determining vertebral fracture risk is biomechanical computed tomography (BCT), which evaluates both bone density and strength. This policy addresses vertebral fracture assessment without densitometry. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION
Not applicable POLICY STATEMENT Medicare Advantage Plans Screening for vertebral fractures using dual-energy X-ray absorptiometry (DXA or DEXA), without bone density study, is covered, but not separately reimbursed. Commercial Products Screening for vertebral fractures using dual-energy X-ray absorptiometry (DXA or DEXA) or biomechanical computed tomography, without bone density study, is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for not medically necessary benefits/coverage. BACKGROUND Vertebral Fractures Vertebral fractures are highly prevalent in the elderly population, and epidemiologic studies have found that these fractures are associated with an increased risk of future spine or hip fractures independent of bone mineral density. Diagnosis Only 20% to 30% of vertebral fractures are recognized clinically; the rest are discovered incidentally on lateral spine radiographs. Lateral spine radiographs have not been recommended as a component of risk assessment for osteoporosis because of the cost, radiation exposure, and the fact that the radiograph would require a separate procedure in addition to the bone mineral density study using dual-energy x-ray absorptiometry. However, several densitometers with specialized software can perform VFA in conjunction with dual-energy x-ray absorptiometry. The lateral spine scan is performed by using a rotating arm; depending on the densitometer used, the patient can either stay in the supine position after the bone density study or is required to move onto the left decubitus position. Medical Coverage Policy | Vertebral Fracture Assessment or Biomechanical Computed Tomography

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

VFA differs from radiologic detection of fractures because VFA uses a lower radiation exposure and can detect only fractures, while traditional radiograph images can detect other bone and soft tissue abnormalities in addition to spinal fractures. Manufacturers have also referred to this procedure as instant vertebral assessment, radiographic vertebral assessment, dual-energy vertebral assessment, or lateral vertebral assessment.

For both lateral spine radiographs and images with densitometry, vertebral fractures are assessed visually. While a number of grading systems have been proposed, the Genant semiquantitative method is commonly used. This system grades the deformities from I to III, with grade I (mild) representing a 20% to 24% reduction in vertebral height, grade II (moderate) representing a 25% to 39% reduction in height, and grade III (severe) representing a 40% or greater reduction in height. The location of the deformity within the vertebrae may also be noted. For example, if only the mid height of the vertebrae is affected, the deformity is defined as an endplate deformity; if both the anterior and mid heights are deformed, it is a wedge deformity; and if the entire vertebrae is deformed, it is classed as a crush deformity. A vertebral deformity of at least 20% loss in height is typically considered a fracture. Accurate interpretation of both lateral spine radiographs and VFA imaging is dependent on radiologic training. Thus, device location and availability of appropriately trained personnel may influence diagnostic accuracy.

Biomechanical computed tomography (BCT) is another method of performing VFA which also minimizes radiation exposure.2, Previously obtained CT scans can be used for BCT analysis in many cases. Exceptions include spinal images performed with contrast and images in which metal is present in the transverse plane of the bone of interest. Analysis is performed in a centralized laboratory, to which clinicians must send CT scans. The BCT calculation involves a non-linear finite element analysis to simulate a fracture event, with outputs including T-score and Z-score of the femoral neck and hip, femoral strength, vertebral strength, vertebral trabecular volume, and vertebral Z-score. Patients are classified as high risk if fragile bone strength (defined as ≤3000 to 6500 Newtons depending on patient sex and location [hip or spine]) or osteoporosis at the hip or spine is found. The classification of increased risk is assigned if low bone strength or low bone mass is identified at the hip or spine.

For individuals who are at risk of having vertebral fractures but are not known to have them who receive VFA with densitometry by dual-energy x-ray absorptiometry, the evidence includes diagnostic accuracy studies and subgroup reanalyses of treatment studies. Relevant outcomes are test accuracy, test validity, and morbid events. There is a lack of direct evidence from screening trials that use densitometry with and without VFA improves health outcomes. Because direct evidence was not available, a chain of evidence was sought. Evidence was examined on the diagnostic accuracy of VFA in nonosteoporotic patients (ie, those not already eligible for treatment), the ability of VFA to identify patients for treatment who would not otherwise be identified, and the effectiveness of treatment in this population. Diagnostic accuracy studies have reported variable findings; recent studies have suggested higher diagnostic accuracy of VFA overall compared with standard radiographs than older studies. Studies have found that VFA can identify patients without osteoporosis who may be appropriate candidates for treatment according to recommendations from the National Osteoporosis Foundation. However, there is limited evidence on the effectiveness of treatment in this population. No treatment data have been published on patients whose vertebral fracture had been identified using VFA software with densitometry. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who are at risk of having vertebral fractures but are not known to have them who receive VFA with biomechanical computed tomography (BCT), the evidence includes retrospective studies. Relevant outcomes are test accuracy, test validity, and morbid events. The available studies have demonstrated that BCT has similar efficacy to DXA in detecting osteoporosis. There is a lack of direct evidence from clinical trials that the use of BCT for VFA improves health outcomes. No treatment data have been published on patients whose vertebral fractures were identified using BCT. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

CODING

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Medicare Advantage Plans and Commercial Products The following CPT code(s) is covered, but not separately reimbursed for Medicare Advantage Plans and is not medically necessary for Commercial Products: 77086 Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

RELATED POLICIES Bone Mineral Density Studies
Non-Reimbursable Health Service Codes

PUBLISHED Provider Update, November, 2025 Provider Update, January 2025 Provider Update, January 2024 Provider Update, January 2023 Provider Update, December 2021

REFERENCES

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

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