Clinical Policy Guideline

Transcription

1 Clinical Policy Guideline Policy Title: Bone Density Testing Policy No: B0215A.00 Effective Date: 01/01/15 Date Reviewed: 03/25/15 I. DEFINITION/BACKGROUND Bone density testing is used to estimate the amount of bone mass in the hips, spine or other bones. Bone density testing can be measured by a variety of techniques. Dual X-ray Absorptiometry (DXA), Quantitative computed tomography (QCT) and Ultrasound Densitometry are the most common tests. The testing is divided into two categories, central sites and peripheral sites. Central sites include the hips, femurs or spine. Peripheral sites include wrists, fingers and heels. The most commonly used done density tests are DXA of the hip and lumbar spine and quantitative ultrasonography of the calcaneus. DXA of the hips and lumbar spine are strongly encouraged for the initial screening for bone density as it is the most accurate. Lower bone density mass can increase the risk of fractures and other associated morbidities and mortalities. Bone density testing is the proven method of confirming osteoporosis or osteopenia. Osteoporosis is excessive bone mass loss, reduced bone mass production, or both. Osteopenia is lower than normal bone mass density, but not low enough to be considered osteoporosis. The benefits of bone density testing are to assist providers in predicting the chances of a fracture and to determine the need for osteoporotic medications. The United States Task Force on Preventative Services (USPSTF) recommends screening for osteoporosis in women 65 years and older, or those women who have the fracture risk score equal to or greater than that of a 65-year old woman and who has no additional risk factors. Member cost sharing is waived per Affordable Care Act age 65 and older. Members between the ages of 60 to 64 only have no member cost sharing if medical criteria is met. In addition, the USPSTF recommends the use of the Fracture Risk Assessment (FRAX) tool to estimate the 10-year risk for fractures. Factors included in this tool include; age, body mass index, tobacco and alcohol consumption as well as post-menopausal status. Evidence is currently lacking for when repeated screenings are beneficial. There is insufficient current evidence to assess the balance of benefits and harms of screening for osteoporosis in men. II. POLICY/CRITERIA HealthPlus of Michigan will cover bone density testing when ordered by a physician or qualified nonphysician practitioner. Only one test per individual during the coverage period is allowed regardless of

2 the number of providers performing the test and is not medically necessary to perform multiple methods of testing. Documentation supporting medical necessity must be demonstrated in the member s medical record. Documentation must be legible and contain relevant history and physical findings to meet the criteria listed below. Bone density testing is covered every two years (at least 23 months since previous test) for the following criteria: 1. A woman determined by a physician or qualified non-physician practitioner to be estrogen deficient. 2. An individual with vertebral abnormalities as demonstrated by x-ray, indicative of osteoporosis, osteopenia or vertebral fracture. 3. An individual receiving glucocorticoid therapy equal to or greater than 5mg of prednisone, per day, more than three months. 4. An individual with primary hyperparathyroidism. 5. An individual being monitored to assess the efficacy of a Food and Drug Administration (FDA) approved osteoporosis drug therapy. Bone density testing is covered more than every two years (at least eleven months since previous test) for the following criteria: 1. Monitoring of long term glucocorticoid therapy greater than 5mg of prednisone, per day, more than three months; or 2. Confirmation of baseline to assist future monitoring; or 3. To assess the efficacy of an FDA approved osteoporosis drug therapy until a response to therapy has been documented. The following are approved procedures for bone density testing for central sites by the Centers for Medicare and Medicaid Services (CMS): 1. Dual energy X-ray absorptiometry (DEXA or DXA) 2. Quantitative computed tomography (QCT) 3. Radiographic absorptiometry 4. Single energy X-ray absorptiometry (SEXA) 5. Ultrasound bone mineral density studies III. PRIOR AUTHORIZATION REQUIREMENTS Not applicable. Page 2 of 5

3 IV. CODING: Ultrasound bone density measurement and interpretation, peripheral site(s), any method Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA) Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry. (Not covered by Medicare) Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry, 1 or more sites. (Not covered by Medicare). G0130 Single energy X-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) DIAGNOSIS CODES: V49.81 asymptomatic postmenopausal status (age-related) (natural) V82.81 screening osteoporosis V. COVERED LOCATIONS OF SERVICE 11 (Office), 22 (Outpatient) VI. PRODUCT LINE COVERAGE Please reference contract benefit rider, benefit description, Master Plan Document, Evidence of Coverage (EoC) and Certificate of Coverage (CoC) for applicable limits and copayments, including other exceptions and/or exclusions for specific coverage. If there is a conflict between this medical policy and the individual or group insurance policy document, the terms of the individual or group insurance policy will govern, unless specifically noted. HMO: This policy applies to insured HMO plans; refer to the CoC or benefit rider for exceptions or exclusions. PPO: This policy applies to PPO plans; refer to the CoC for any exceptions or exclusions. Page 3 of 5

4 SELF-FUNDED OPTIONS: This policy applies to self-funded option plans; refer to the Master Plan Document for any exceptions or exclusions. MEDICARE ADVANTAGE: This policy applies to insured Medicare Advantage plans; refer to the EoC for any exceptions or exclusions. MEDICAID: This policy applies to Medicaid plans; refer to the subscriber contract for exceptions or exclusions. HEALTHY MICHIGAN PLAN: This policy applies to Healthy Michigan Plan; refer to the subscriber contract for any exceptions or exclusions. MICHILD: This policy applies to insured MICHILD plans; refer to the subscriber contract for any exceptions or exclusions. COUNTY HEALTH PLANS: This policy applies to County Health Plans; refer to the benefit rider for any exceptions or exclusions. VII. REFERENCES Centers for Medicare and Medicaid Services, Local Coverage Determination, Bone Mass Measurement (L31620): details.aspx?lcdid=31620&contrid=267 The National Osteoporosis Foundation (NOF) Clinician s Guide to Prevention and Treatment of Osteoporosis: U.S. Preventative Services Task Force, osteoporosis Screening: AMA CPT Copyright Statement: All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the American Medical Association. This policy is for informational use only; therefore it is not an authorization of services. HealthPlus of Michigan s clinical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, HealthPlus of Michigan reserves the right to review and update its clinical policies at its discretion. Page 4 of 5

5 HealthPlus of Michigan s clinical policies are intended to serve as a resource to the plan; however they are not intended to limit the plan s interpretation of benefit language. HealthPlus of Michigan does not provide health care services and cannot guarantee results or outcomes. Treating providers are solely responsible for rendering medical advice and treatment to members. Page 5 of 5