Humana Commercial Clinical Policy

Humana Bone Density Measurement Form

Effective Date

01/01/2024

Last Reviewed

NA

Original Document

  Reference



Description

Osteoporosis is a disease in which bones become brittle or fragile from loss of tissue. It may be related to aging, associated with certain medical conditions or a result of pharmacotherapy. If osteoporosis is undetected and left untreated, loss of bone mass may result in fractures.

Measurement of bone mineral density (BMD) may be utilized for the diagnosis and treatment of decreased bone mass. There are a variety of techniques designed for aiding in this measurement. These include, but may not be limited to:

  • Dual-energy X-ray absorptiometry (DXA) is the best available clinical tool for the diagnosis of osteoporosis and monitoring changes in bone mineral density over time. DXA sends two types of energy level X-ray beams which are absorbed differently by bones and soft tissue. Strong, dense bones allow less of the X-ray beam to pass through them. The density profiles from these X-rays are used to calculate BMD. The lower the density, the greater risk of fracture. Results are presented as T-scores, which are the number of standard deviations (units) that bone density is above or below the average for a healthy adult or as Z-scores, which compares the bone density to an average individual of the same age as the individual tested. Central DXA scans consist of a large, flat table with a radiographic arm suspended overhead. Peripheral DXA (pDXA) devices are portable instruments that use the same DXA technology, however measure bone density via the heel, wrist or finger.
  • Vertebral fracture assessment (VFA) is a test that is performed at the same time as a central DXA scan. It is used to identify previously undetected vertebral compression fractures and evaluate the risk for future fractures. While this test does not measure bone density, the presence of vertebral factors can indicate a higher risk of fractures elsewhere in the body and may change diagnostic classification or clinical management.
  • Whole body DXA is a method purported to determine body composition, by measuring the relative proportions of fat and lean mass in the body. Lean mass refers to bones, muscles, organs and tissues. This testing is typically confined to clinical or research settings when a more rigorous determination of body composition is needed. (Refer to Coverage Limitations section)
  • Artificial intelligence (AI) technology purported to identify vertebral compression fractures by utilizing automated analysis during computed tomography (CT) scanning of the abdomen/chest or osteoporosis/osteopenia from digital X-ray radiogrammetry via a cloud-based screening method are other possibilities being explored for assessing bone disease. The Nanox.AI and OsteoApp.ai are examples. (Refer to Coverage Limitations section)
  • Bone turnover markers (BTM)/biochemical markers are laboratory-based tests of serum or urine, purported to measure the rate of bone loss. Biochemical markers of bone turnover are products released from osteoblasts and osteoclasts or collagen breakdown products. C-telopeptide crosslink (CTX), N-telopeptide crosslink (NTX) and pyridinium crosslinks (PYD/DPD) are markers of bone resorption. Bone-specific alkaline phosphatase (BSAP/BALP), osteocalcin (OC) and procollagen type I propeptides (C-terminal [PICP] and N-terminal [PINP]) are markers of bone formation.

Bone Density Measurement
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022

Page: 1 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Assay variability and poor standardization have limited the use of BTMs in clinical practice.49 (Refer to Coverage Limitations section)

  • Dual-photon absorptiometry (DPA) and single-photon absorptiometry (SPA) are older methods of testing purported to measure bone density using a photon beam at one or two distinct energy levels. These two tests have been replaced by DXA, due to improved accuracy. (Refer to Coverage Limitations section)
  • Microindentation of the tibia is a suggested bone density test utilizing a device that invasively indents the tibia bone to produce microfractures. If the microfractures occur easily, the probe indents deeper and the resulting bone quality score is lowered. An example of this type of device is the OsteoProbe. (Refer to Coverage Limitations section)
  • Pulse-echo ultrasound is a test in which a small, handheld device is used to purportedly measure cortical bone thickness of the tibia. Bindex is an example of this device. (Refer to Coverage Limitations section)
  • Radiofrequency echographic multi-spectrometry (REMS) is a portable, radiation-free technology that is being investigated as a potential alternative for assessing bone density and quality on the lumbar vertebrae and proximal femur. Bone microarchitecture is characterized using radiofrequency signals acquired during an ultrasound scan. This has been created in an effort to overcome some of the limitations of DXA. An example of this technology is the EchoS. (Refer to Coverage Limitations section)
  • Quantitative computed tomography (QCT) is a test intended to distinguish trabecular bone (soft bone) from cortical bone (hard bone) to measure BMD of the proximal femur or spine. Peripheral QCT (pQCT) measures the same at the radius or tibia. The CliniQCT and QCT Pro is a type of software that purportedly allows for the measurement of BMD at the same time any non-IV contrast abdominal or pelvic CT has been performed for another purpose.
  • VirtuOst, is another type of QCT, which also uses data from previously acquired CT scans (known as Biomechanical Computed Tomography [BCT] analysis) through finite element analysis (FEA). FEA uses computer models of images as well as data from QCT to assess bone strength, bone mineral density, classification of any vertebral fractures and/or overall fracture risk assessment. (Refer to Coverage Limitations section)
  • Quantitative ultrasound densitometry (QUS) is proposed to measure BMD using speed of sound (SOS) and/or broadband ultrasound attenuation (BUA) at the heel, tibia, patella and other peripheral skeletal sites. It is suggested that a composite parameter using SOS and BUA may be used clinically. (Refer to Coverage Limitations section)
  • Single-energy X-ray absorptiometry (SEXA, SXA) is suggested to measure the absorption of a monochromatic photon beam by bone material, usually in the heel and forearm. Similar to the DXA scan, the SXA uses only one X-ray beam energy source aimed at the bones as it passes over the individual. (Refer to Coverage Limitations section)
  • Trabecular bone score (TBS) software is intended as a complement to both DXA analysis and clinical examination. It allegedly assesses the structural condition or textural component of bone microarchitecture, which may provide information that is not captured from standard BMD measurement. TBS Osteo powered by TBS iNsight is an example of this technology.

Bone Density Measurement

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022
Page: 4 of 18

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(Refer to Coverage Limitations section)

Coverage Determination

Humana members may be eligible under the Plan for DXA (77080, 77081) once every 2 years when the following criteria are met:

  • Screening for osteoporosis in female:
    • 65 years of age or older; OR
    • Postmenopausal female 64 years of age or younger at increased risk of osteoporosis as determined by a formal fracture risk assessment tool (eg, FRAX tool)76
  • Humana members may be eligible under the Plan for vertebral fracture assessment from DXA (77085, 77086) once every 2 years when T-score is less than -1.0 and when any of the following criteria are met:
    • Females 70 years of age or older; OR
    • Males 80 years of age or older; OR
    • Historical height loss greater than 4 cm (greater than 1.5 inches); OR
    • Glucocorticoid therapy (eg, 5 mg or greater of prednisone or equivalent per day for greater than or equal to 3 months)

Note: The criteria for bone density measurement are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for DXA (77080, 77081, 77085, 77086) for any indications other than those listed above including, but may not be limited to, the following:

  • Determining body composition/whole body DXA; OR
  • Screening of males

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for any BMD measurement other than DXA including, but may not be limited to, the following:

  • Bone turnover markers (BTM)/biochemical markers (82523, 83937, 84075); OR
  • Dual photon absorptiometry (DPA) (78531); OR
  • Radiofrequency echographic multi-spectrometry (REMS) (eg, EchoS) (0815T); OR
  • Microindentation of the tibia (eg, OsteoProbe) (0547T); OR
  • Pulse-echo ultrasound (eg, Bindex) (0508T); OR
  • Quantitative computed tomography, with or without finite element analysis (eg, CliniQCT/QCT Pro, VirtuOst) (77078, 0554T, 0555T, 0556T, 0557T, 0558T, 0743T); OR
  • Quantitative ultrasound densitometry (QUS) (76977); OR
  • Single-energy X-ray absorptiometry (SXA) (G0130); OR
  • Single-photon absorptiometry (SPA) (78350); OR
  • Trabecular bone score (eg, TBS Osteo powered by TBS iNsight) (77089, 77090, 77091, 77092)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for AI technology intended to detect:

  • Osteoporosis/osteopenia from digital X-ray radiogrammetry via a cloud-based screening method (eg, OsteoApp.ai) (0749T, 0750T); OR
  • Vertebral fractures during abdomen/chest CT scans using automated analysis (eg, Nanox.AI) (0691T)

This is considered not medically necessary as defined in the member’s individual certificate.

Bone Density Measurement

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022
Page: 6 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Please refer to the member's individual certificate for the specific definition.

Additional information about bone health and osteoporosis may be found from the following websites:

  • Bone Health & Osteoporosis Foundation
  • National Library of Medicine

Bone Density Measurement

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022
Page: 7 of 18

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Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Provider Claims Codes
CPi” Code(s)DescriptionComments
76499Unlisted diagnostic radiographic procedureNot Covered if used to report any BMD measurement outlined in Coverage Limitations section
76977Ultrasound bone density measurement and interpretation, peripheral site(s), any methodNot Covered
77078Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine)Not Covered
77080Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
77081Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)
77085Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment
77086Vertebral fracture assessment via dual-energy X-ray . absorptiometry (DXA)
77089Trabecular bone score (TBS), structural condition of the bone microarchitecture; using dual X-ray absorptiometry (DXA) or other imaging data on gray-scale variogram,Not Covered

Bone Density Measurement

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022
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77090Trabecular bone score (TBS), structural condition of the bone microarchitecture; technical preparation and transmission of data for analysis to be performed elsewhereNot Covered
77091Trabecular bone score (TBS), structural condition of the bone : . ( : ) . microarchitecture; technical calculation onlyNot Covered
77092Trabecular bone score (TBS), structural condition of the bone microarchitecture; interpretation and report on fracture-risk only by other qualified health care professionalNot Covered
78350Bone density (bone mineral content) study, 1 or more sites; . v( . )
78351Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry, 1 or more sitesNot Covered
82523Collagen cross links, any methodNot Covered if used to report any BMD measurement outlined in Coverage Limitations section
83937Osteocalcin (bone g1a protein)Not Covered if used to report any BMD measurement outlined in Coverage Limitations section
84075Phosphatase, alkaline;Not Covered if used to report any BMD measurement outlined in Coverage Limitations section
CPT® Category Ill Code(s)DescriptionComments
0508TPulse-echo ultrasound bone density measurement resulting in indicator of axial bone mineral density, tibiaNot Covered
0547TBone-material quality testing by microindentation(s) of the tibia(s), with results reported as a scoreNot Covered

Bone Density Measurement

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022
Page: 9 of 18

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 andNot Covered
O555Tbone mineral density, interpretation and report Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a : on computed tomography scan; retrieval and transmission of theNot Covered
scan data Bone strength and fracture risk using finite element analysis of
OSS6Tfunctional data, and bone-mineral density, utilizing data from a , Y, 8 computed tomography scan; assessment of bone strength and fracture risk and bone mineral density Bone and fracture risk finite element ofNot Covered
0557Tstrength using analysis functional data, and bone-mineral density, utilizing data from a computed tomography scan; interpretation and reportNot Covered
0558TComputed tomography scan taken for the purpose of biomechanical computed tomography analysisNot Covered
0691TAutomated analysis of an existing computed tomography study for vertebral fracture(s), including assessment of bone density when performed, data preparation, interpretation, and reportNot Covered
0743TBone strength and fracture risk using finite element analysis of functional data and bone-mineral density, with concurrent vertebral fracture assessment, utilizing data from a computed tomography scan, retrieval and transmission of the scan data, measurement of bone strength and bone mineral density and classification of any vertebral fractures, with overall fracture risk assessment, interpretation and reportNot Covered
0749TBone strength and fracture-risk assessment using digital X-ray radiogrammetry- bone mineral density (DXR-BMD) analysis of bone mineral density (BMD) utilizing data from a digital X ray, retrieval and transmission of digital X ray data, assessment ofNot Covered

Bone strength and fracture-risk assessment using digital X-ray radiogrammetry- bone mineral density (DXR-BMD) analysis of bone mineral density (BMD) utilizing data from a digital X ray, retrieval and transmission of digital X ray data, assessment of bone strength and fracture-risk and BMD, interpretation and report;

Bone Density Measurement

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

radiogrammetry- bone mineral density (DXR-BMD) analysis of
0750Tbone mineral density (BMD) utilizing data from a digital X ray, retrieval and transmission of digital X ray data, assessment of bone strength and fracture-risk and BMD, with single-view digital X-ray examination of the hand taken for the purpose of DXR-BMDNot Covered
0815TUltrasound-based radiofrequency echographic multi- spectrometry (REMS), bone-density study and fracture-risk assessment at various sites, hips pelvis spine, etc.Not Covered. New Code Effective 01/01/2024

HCPCS Code(s)

G0130Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)Not Covered

References

  1. American Academy of Pediatrics (AAP). Clinical Report. Bone densitometry in children and adolescents. https://www.aap.org. Published October 2016. Accessed April 18, 2023.
  2. American Association of Clinical Endocrinologists (AACE). American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. https://www.aace.com. Published May 2020. Accessed April 20, 2023.
  3. American Association of Clinical Endocrinologists (AACE). American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients. https://www.aace.com. Published November 1, 2002. Accessed April 20, 2023.
  4. American College of Obstetricians and Gynecologists (ACOG). Clinical Practice Guideline. Management of postmenopausal osteoporosis. https://www.acog.org. Published April 2022. Accessed April 20, 2023.
  5. Bone Density Measurement Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 05/25/2023 Policy Number: HUM-0499-022 Page: 11 of 18

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  6. American College of Obstetricians and Gynecologists (ACOG). Clinical Practice Guideline. Osteoporosis prevention, screening, and diagnosis. https://www.acog.org. Published September 2021. Accessed April 20, 2023.
  7. American College of Physicians (ACP). Clinical Guidelines (ARCHIVED). Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. https://www.acponline.org. Published May 6, 2008. Accessed April 18, 2023.
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  10. American College of Radiology (ACR). ACR–SPR–SSR practice parameter for the performance of dual-energy x-ray absorptiometry (DXA). https://www.acr.org. Published 1998. Updated 2018. Accessed April 25, 2023.
  11. American College of Rheumatology (ACR). 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid- induced osteoporosis. https://www.rheumatology.org. Published November 9, 2022. Accessed April 25, 2023.
  12. American Society of Clinical Oncology (ASCO). American Cancer Society/ American Society of Clinical Oncology breast cancer survivorship care guideline. https://www.asco.org. Published December 7, 2015. Accessed April 25, 2023.
  13. American Society of Clinical Oncology (ASCO). Management of osteoporosis in survivors of adult cancers with nonmetastatic disease: ASCO clinical practice guideline. https://www.asco.org. Published September 18, 2019. Accessed April 25, 2023.

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Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022
Page: 12 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. Bone Health and Osteoporosis Foundation (BHOF). Consensus Statement. The clinician’s guide to prevention and treatment of osteoporosis. https://www.bonehealthandosteoporosis.org. Published April 28, 2022. Accessed April 18, 2023.
  2. Caffarelli C, Dea Tomai Pitinca M, Al Refaie A, De Vita M, Catapano S, Gonnelli S. Could radiofrequency echographic multispectrometry (REMS) overcome the overestimation in BMD by dual-energy X-ray absorptiometry (DXA) at the lumbar spine? BMC Musculoskelet Disord. 2022;23(1):469.
  3. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Bone (mineral) density studies (150.3). https://www.cms.gov. Published January 1, 2007. Accessed April 18, 2023.
  4. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Collagen crosslinks, any method (190.19). https://www.cms.gov. Published November 25, 2002. Accessed April 18, 2023.
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  9. Bone Density Measurement Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 05/25/2023 Policy Number: HUM-0499-022 Page: 13 of 18

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  10. ECRI Institute. Hotline Response (ARCHIVED). Biochemical markers of bone turnover in age-related osteoporosis. https://www.ecri.org. Published March 20, 2008. Updated April 12, 2018. Accessed March 14, 2023.
  11. Endocrine Society. Clinical Practice Guideline. Functional hypothalamic amenorrhea: an Endocrine Society clinical practice guideline. https://www.endocrine.org. Published May 2017. Accessed April 20, 2023.
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  13. Endocrine Society. Clinical Practice Guideline. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. https://www.endocrine.org. Published March 17, 2018. Accessed April 20, 2023.
  14. Endocrine Society. Clinical Practice Guideline. Treatment of symptoms of the menopause: an Endocrine Society clinical practice guideline. https://www.endocrine.org. Published November 2015. Accessed April 20, 2023.
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  16. Hayes, Inc. Health Technology Assessment. Trabecular bone score to predict fracture risk in postmenopausal patients. https://evidence.hayesinc.com. Published January 11, 2023. Accessed March 14, 2023.
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Accessed March 14, 2023.Bone Density Measurement
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. Hayes, Inc. Medical Technology Directory (ARCHIVED). Quantitative computed tomography for bone mineral density. https://evidence.hayesinc.com. Published December 8, 2010. Updated January 21, 2014. Accessed March 14, 2023.
  2. Hayes, Inc. Medical Technology Directory (ARCHIVED). Urinary cross-linked N-telopeptide of type I collagen biomarker for diagnosis of osteoporosis and fracture risk assessment. https://evidence.hayesinc.com. Published May 26, 2010. Updated May 6, 2014. Accessed March 14, 2023.
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  9. Shevroja E, Lamy O, Kohlmeier L, Koromani F, Rivadeneira F, Hans D. Use of trabecular bone score (TBS) as a complementary approach to dual-energy X-ray absorptiometry (DXA) for fracture risk assessment in clinical practice. J Clin Densitom. 2017;20(3):334-345.

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Revision Date: 01/01/2024
Review Date: 05/25/2023
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

38. Testing.com: for health professionals. Bone density tests. https://www.testing.com. Updated January 7, 2022. Accessed April 20, 2023.
39. Testing.com: for health professionals. Bone markers. https://www.testing.com. Updated November 9, 2021. Accessed April 20, 2023.
40. Testing.com: for health professionals. Osteoporosis testing. https://www.testing.com. Updated April 8, 2022. Accessed April 20, 2023.
41. The International Society for Clinical Densitometry (ISCD). 2019 ISCD official positions – adult. https://www.iscd.org. Updated 2019. Accessed April 18, 2023.
42. The International Society for Clinical Densitometry (ISCD). 2019 ISCD official positions – pediatric. https://www.iscd.org. Updated 2019. Accessed April 18, 2023.
43. The North American Menopause Society (NAMS). Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. https://www.menopause.org. Published 2021. Accessed April 18, 2023.
44. UpToDate, Inc. Anorexia nervosa: endocrine complications and their management. https://www.uptodate.com. Updated March 2023. Accessed May 1, 2023.
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46. UpToDate, Inc. Approach to the patient following treatment for breast cancer. https://www.uptodate.com. Updated March 7, 2023. Accessed May 1, 2023.
47. UpToDate, Inc.

  1. UpToDate, Inc. Bone disease in diabetes mellitus. https://www.uptodate.com. Updated March 2023. Accessed May 1, 2023.
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  3. UpToDate, Inc. Bone problems in childhood cancer patients. https://www.uptodate.com. Updated March 2023. Accessed May 1, 2023.
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Bone Density Measurement
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 05/25/2023
Policy Number: HUM-0499-022
Page: 17 of 18

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    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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