Bone Mineral Density Studies Form

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|01|2021 POLICY LAST REVIEWED: 09|17|2025 OVERVIEW Bone mineral density (BMD) studies can be used to identify individuals with osteoporosis and monitor response to osteoporosis treatment, with the goal of reducing the risk of fracture. Bone density is most commonly evaluated with dual X-ray absorptiometry (DXA); other technologies are also available.
Medicare Advantage Plans This policy addresses bone density studies that are not covered for Medicare Advantage Plans OR are covered and not considered preventive services. For bone density studies covered as preventive services, please refer to the Preventive Services for Medicare Advantage Plans policy.
Commercial Products This policy addresses bone density studies that are not medically necessary for Commercial Products OR are covered and not considered preventive services. For bone density studies covered as preventive services, please refer to the Preventive Services for Commercial Members policy.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Prior authorization review is not required. POLICY STATEMENT Medicare Advantage Plans Ultrasound bone density measurement using pulse-echo ultrasound is covered. Bone density (bone mineral content) study, one or more sites; using single photon absorptiometry (SPA) or dual photon absorptiometry (DPA) is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products Bone densitometry testing, using Dual energy X Ray absorptiometry (DXA) of the axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment is covered.
Bone densitometry testing, using Dual energy X Ray absorptiometry (DXA) of the appendicular skeleton (peripheral) (e.g. radius, wrist, heel) is covered.
Computed tomography bone mineral density study is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. Ultrasound bone density measurement, including using pulse-echo ultrasound and interpretation and single energy X-ray absorptiometry is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. Medical Coverage Policy | Bone Mineral Density Studies

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

Bone density (bone mineral content) study, one or more sites; using single photon absorptiometry (SPA) or dual photon absorptiometry (DPA) 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 Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable Diagnostic Imaging, Lab and Machine Tests and not medically necessary/not covered benefits/coverage.

BACKGROUND BONE MINERAL DENSITY Risk factors for fracture include low bone mass, low bone strength, a personal history of fracture as an adult, or a history of fracture in a first-degree relative. Osteoporosis, defined as low bone mass leading to an increased risk of fragility fractures, is an extremely common disease in the elderly population due to age- related bone loss in both sexes and menopause-related bone loss in women. The World Health Organization (WHO) has diagnostic thresholds for osteoporosis based on bone mineral density (BMD) measurements compared with a T score, which is the standard deviation difference between an individual’s BMD and that of a young-adult reference population. Conditions that can cause or contribute to osteoporosis include lifestyle factors such as low intake of calcium, high intake of alcohol or cigarette smoking, and thinness. Other risk factors for osteoporosis include certain endocrine, hematologic, gastrointestinal tract and genetic disorders, hypogonadal states, and medications.

BMD can be measured either centrally (i.e., hip or spine) or peripherally (i.e., wrist, finger, heel) sites. While BMD measurements are predictive of fragility fractures at all sites, central measurements of the hip and spine are the most predictive. Fractures of the hip and spine (i.e., vertebral fractures) are also considered to be the most clinically relevant. BMD is typically expressed as a T score.

The utility of screening BMD measurements can be established by demonstrating that screening identifies a population at increased risk of fracture and that, by treating those at-risk individuals, the rate of fractures is reduced thereby lowering fracture-related morbidity and mortality. These potential benefits of screening should outweigh the risks of screening (radiation exposure) or false positives (initiation of unnecessary treatment).

Osteoporosis Treatment Treatment of osteoporosis includes both lifestyle measures (eg, increased intake of calcium and vitamin D, exercise, smoking cessation) and pharmacologic measures. Current pharmacologic options include bisphosphonates such as alendronate (ie, Fosamax), selective estrogen receptor modulators such as raloxifene (ie, Evista), the recombinant human parathyroid hormone teriparatide (ie, Forteo), and calcitonin. A 2014 systematic review funded by the Agency for Healthcare Research and Quality found good-quality evidence that bisphosphonates, denosumab, teriparatide, and raloxifene reduce fracture risk in postmenopausal women with BMD in the osteoporotic range and/or preexisting hip or vertebral fracture.

The decision to perform bone density assessment should be based on an individual’s fracture risk profile and skeletal health assessment. In addition to age, sex, and BMD, risk factors included in the WHO Fracture Risk Assessment (FRAX) Tool are: • Low body mass index; • Parental history of hip fracture; • Previous fragility fracture in adult life (ie, occurring spontaneously or a fracture arising from trauma, which, in a healthy individual, would not have resulted in a fracture); • Current smoking or 3 or more units of alcohol daily, where a unit is equivalent to a standard glass of beer (285 mL), a single measure of spirits (30 mL), a medium-sized glass of wine (120 mL), or 1 measure of an aperitif (60 mL); • A disorder strongly associated with osteoporosis, which includes rheumatoid arthritis, type I (insulin- dependent) diabetes, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism,

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hypogonadism or premature menopause (<45 years), chronic malnutrition or malabsorption, and chronic liver disease; • Current exposure to oral glucocorticoids or exposure to oral glucocorticoids for more than 3 months at a dose of prednisolone 5 mg daily or more (or equivalent doses of other glucocorticoids).

Measurement Tools The following technologies are most commonly used to measure BMD.

1. Dual X-Ray Absorptiometry (DXA)
   DXA is the most commonly used technique to measure BMD because of its ease of use, low radiation exposure, and its ability to measure BMD at both the hip and spine. DXA can also be used to measure peripheral sites, such as the wrist and finger. DXA generates 2 x-ray beams of different energy levels to scan the region of interest and measure the difference in attenuation as the low- and high-energy beams pass through the bone and soft tissue. The low-energy beam is preferentially attenuated by bone, while the high- energy beam is attenuated by both bone and soft tissue. This difference in attenuation between the 2 beams allows for correction for the irregular masses of soft tissue, which surround the spine and hip, and therefore the measurement of bone density at those sites.

2. Quantitative Computed Tomography (QCT)
   QCT depends on the differential absorption of ionizing radiation by calcified tissue and is used for central measurements only. Compared to DXA, QCT is less readily available and associated with relatively high radiation exposure and relatively high cost. Analysis of previously obtained clinical CT scans of the pelvis might provide an alternative method of assessing biomechanical bone strength.

   Dual x-ray absorptiometry (DXA) of axial central sites (ie, hip and spine) is the most commonly used technique, but peripheral (appendicular) DXA and quantitative computed tomography scanning are sometimes used, based on local availability. Peripheral measurement can identify patients with low bone mass but does not predict response to pharmacologic therapy and is not a substitute for central DXA measurements. Therefore, central DXA (hip/spine) is required for both the initial diagnosis and repeat bone mineral density (BMD) assessments.

   Peripheral measurement of BMD may be appropriate: • If the hip/spine or hip/hip cannot be done or the patient is over the table limit for weight; • Hyperparathyroidism, where the forearm is essential for diagnosis.

3. Ultrasound Densitometry
   Ultrasound densitometry is a technique for measuring BMD at peripheral sites, typically the heel but also the tibia and phalanges. Compared to osteoporotic bone, normal bone demonstrates higher attenuation of the ultrasound wave and is associated with a greater velocity of the wave passing through bone. Ultrasound densitometry has no radiation exposure, and machines may be purchased for use in an office setting. It is unknown whether this technology can be used to predict response to pharmacologic therapy (ie, reduce fractures).

   These techniques dominate BMD testing. Single- and dual-photon absorptiometry and radiographic absorptiometry are now rarely used and may be considered obsolete.

   An initial measurement of BMD at the hip or spine may be considered medically necessary to assess 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, regardless of other risk factors; • Men age 70 and older, regardless of other risk factors; • Younger postmenopausal women about whom there is a concern based on their risk factors; • Men age 50-70 about whom there is a concern based on their risk factors;

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

• Adults with a condition or taking a medication associated with low bone mass or bone loss.

Note: Covered DXA services must be provided on a device capable of performing a central DXA and must include permanent image storage, interpretation and report.

For individuals who are eligible for screening of BMD based on risk factor assessment who receive ultrasound densitometry, quantitative computed tomography, or DXA analysis of peripheral sites, the evidence includes observational studies and systematic reviews. Relevant outcomes are morbid events, functional outcomes, quality of life, hospitalizations, and medication use. The 2025 USPSTF recommendation statement on screening for osteoporosis to prevent fractures does not review imaging modalities other than central DXA. Studies show that in comparison with central DXA, other measures of bone health showed area under the curves around 0.80 for the identification of osteoporosis. One systematic review demonstrated that quantitative computed tomography identified significantly more osteoporosis cases than DXA. Overall, these technologies are not commonly used for BMD measurements in practice, and no studies have shown that they can select patients who benefit from treatment for osteoporosis. There is little to no evidence on the usefulness of repeat measurement of BMD using these techniques. There is little to no evidence on the usefulness of repeat measurement of BMD using these techniques. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

CODING Please see the Preventive Services for Medicare Advantage Plans or Preventive Services for Commercial Products policies for coverage of any CPT codes for bone density studies not listed below.

Medicare Advantage Plans and Commercial Products The following CPT code(s) are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: 78350 Bone density (bone mineral content) study, one or more sites; single photon absorptiometry (SPA)
78351 Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry (DPA)

Commercial Products
*Note: For Medicare Advantage Plans, with the exception of CPT code 0508T (above), please refer to related policy, Preventive Services for Medicare Advantage Plans for all of the following CPT codes.
The following CPT code(s) are covered: 77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton

(peripheral) (e.g., 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

The following CPT code(s) are not medically necessary: 76977 Ultrasound bone density measurement and interpretation 77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis,

spine) G0130 Single energy X-ray absorptiometry (SEXA) bone density study, 1 or more sites; appendicular

skeleton (peripheral) (e.g. radius, wrist, heel) 0554T Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral

density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data,

assessment of bone strength and fracture risk and bone mineral density, interpretation and report 0555T Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral

density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data 0556T Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral

density, utilizing data from a computed tomography scan; assessment of bone strength and fracture

risk and bone mineral density 0557T Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral

density, utilizing data from a computed tomography scan; interpretation and report

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

0558T Computed tomography scan taken for the purpose of biomechanical computed tomography analysis

RELATED POLICIES Preventive Services for Commercial
Preventive Services for Medicare Advantage Plans
Vertebral Fracture Assessment

PUBLISHED Provider Update, November 2025 Provider Update, January/November 2024
Provider Update, January 2023 Provider Update, February 2022 Provider Update, February 2021

REFERENCES

1. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination for Bone (Mineral) Density Studies (150.3).
2. World Health Organization (WHO). FRAX: Fracture Risk Assessment Tool. n.d.; http://www.shef.ac.uk/FRAX/tool.jsp. Accessed July 22, 2025.
3. U.S. Preventive Services Task Force (USPSTF). Osteoporosis: Screening to Prevent Fractures. 2018; https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening. Accessed July 22, 2025.
4. Kahwati LC, Kistler CE, Booth G, et al. Screening for Osteoporosis to Prevent Fractures: An Evidence Review for the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); January 2025.
5. Camacho PM, Petak SM, Binkley N, et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICALPRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS-2020 UPDATE. Endocr Pract. May 2020; 26(Suppl 1): 1-46. PMID 32427503
6. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. Jun 2012; 97(6): 1802-22. PMID 22675062
7. 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. May06 2008; 148(9): 680-4. PMID 18458281
8. Agency for Healthcare Research and Quality. Treatment To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis: Update of a 2007 Report. 2012; https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/osteoporosis-bone-fracture_research.pdf. Accessed July 22, 2025.
9. Bell KJ, Hayen A, Macaskill P, et al. Value of routine monitoring of bone mineral density after starting bisphosphonate treatment: secondary analysis of trial data. BMJ. Jun 232009; 338: b2266. PMID 19549996
10. Eastell R, Rosen CJ, Black DM, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab. May 01 2019; 104(5): 1595-1622. PMID 30907953
11. Shoback D, Rosen CJ, Black DM, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. Mar 01 2020; 105(3). PMID 32068863
12. Curry SJ, Krist AH, Owens DK, et al. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. Jun 26 2018; 319(24): 2521-2531. PMID 29946735
13. Yang J, Zeng Y, Yu W. Criteria for osteoporosis diagnosis: a systematic review and meta-analysis of osteoporosis diagnostic studies with DXA and QCT.EClinicalMedicine. May 2025; 83: 103244. PMID 40630613

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 6 (401) 274-4848 WWW.BCBSRI.COM

14. Adams AL, Fischer H, Kopperdahl DL, et al. Osteoporosis and Hip Fracture Risk From Routine Computed Tomography Scans: The Fracture, Osteoporosis, and CT Utilization Study (FOCUS). J Bone Miner Res. Jul 2018; 33(7): 1291-1301. PMID 29665068
15. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. Sep 01 2021; 138(3): 494-506. PMID 34412075
16. Qaseem A, Forciea MA, McLean RM, et al. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians. Ann Intern Med. Jun 06 2017; 166(11): 818-839. PMID 28492856
17. Qaseem A, Hicks LA, Etxeandia-Ikobaltzeta I, et al. Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians. Ann Intern Med. Feb 2023; 176(2): 224-238. PMID 36592456
18. Yu JS, Krishna NG, Fox MG, et al. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. Nov 2022; 19(11S): S417-S432. PMID 36436967
19. Adler RA, El-Hajj Fuleihan G, Bauer DC, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. Oct 2016; 31(10): 1910. PMID 27759931
20. Cosman F, Lewiecki EM, Eastell R, et al. Goal-directed osteoporosis treatment: ASBMR/BHOF task force position statement 2024. J Bone Miner Res. Sep 26 2024;39(10): 1393-1405. PMID 39073912
21. The International Society for Clinical Densitometry. Adult Official Positions of the ISCD. 2019; https://iscd.org/learn/official-positions/adult-positions/. Accessed July 22, 2025.
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23. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. Apr 28 2022. PMID 35478046

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber a greement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS