449 Form

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Medical Policy Vertebral Fracture Assessment with Densitometry or Biomechanical Computed Tomography
Table of Contents
• Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 449 BCBSA Reference Number: 6.01.44 (For Plan internal use only) NCD/LCD: NA Related Policies
• Medicare Advantage Management, #132 • Bone Mineral Density Studies, #450 • Whole Body Dual X-Ray Absorptiometry to Determine Body Composition, #577

Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Screening for vertebral fractures using dual x-ray absorptiometry (DEXA or DXA) or biomechanical computed tomography is INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

2 Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list. The following CPT code is considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes: Code Description 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 is considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT codes: Code Description 77086 Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA) 0743T Bone strength and fracture risk using finite element analysis of functional data and bone mineral density (BMD), with concurrent vertebral fracture assessment, utilizing data from a computed tomography scan, retrieval and transmission of the scan data, measurement of bone strength and BMD and classification of any vertebral fractures, with overall fracture-risk assessment, interpretation and report

Description Diagnosis Only 20% to 30% of vertebral fractures are recognized clinically; the rest are discovered incidentally on lateral spine radiographs or other imaging studies.1, 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 (BMD) study using dual-energy x-ray absorptiometry (DXA). However, several densitometers with specialized software can perform vertebral fracture assessment (VFA) in conjunction with DXA. 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 to the left decubitus position. Vertebral fracture assessment 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. A number of grading systems have been proposed, and the Genant semiquantitative method is commonly used. This system grades 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 depends on radiologic training. Thus, device location and availability of appropriately trained personnel may influence diagnostic accuracy.

3 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.

Summary Description Vertebral fracture assessment (VFA) with densitometry is a technique to assess vertebral fractures at the same time as bone mineral density (BMD), using additional software with dual-energy x-ray absorptiometry (DXA). The addition of VFA to BMD 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.

Summary of Evidence For individuals who are at risk of having vertebral fractures but are not known to have them who receive vertebral fracture assessment (VFA) with densitometry by dual-energy x-ray absorptiometry (DXA), the evidence includes diagnostic accuracy studies and subgroup re-analyses 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 of densitometry with 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 non-osteoporotic 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 Bone Health and 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 fractures were identified using VFA software with densitometry. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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.

Policy History
Date Action 11/2025 Annual policy review. Policy updated with literature review through July 19, 2025; reference added. Policy statement unchanged. 5/2025 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference. 3/2025 Annual policy review. Policy updated with literature review through August 21, 2024. References added. Investigational indication for biomechanical computed tomography added. Clarified coding information. Effective 3/1/2025.

4 11/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 12/2022 Clarified coding information. 10/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 11/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 11/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2017 Annual policy review. New references added. 10/2016 Annual policy review. New references added. 1/2015 Clarified coding information. 2/2013 Annual policy review. New references added. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
9/2011 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology. No changes to policy statements. 1/2011 Annual policy review. No changes to policy statements. 10/2010 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology. No changes to policy statements. 10/2009 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology. No changes to policy statements. 10/2008 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology. No changes to policy statements. 10/2007 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology. No changes to policy statements. 8/2007 Annual policy review. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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