Bone (Mineral) Density Studies Policy Number: MM.05.002 Line(s) of Business: HMO; PPO; QUEST Integration Section: Radiology Place(s) of Service: Outpatient

Original Effective Date: 03/23/2001 Current Effective Date: 10/24/2014

I. Description

A bone mineral density (BMD) study is a non-invasive technique that is used to measure bone mineral content and bone mineral density. Its primary role is to detect osteoporosis and to predict the risk of fractures. Osteoporosis is a disease that results in the loss of bone mineral content or bone density. This leads to thinning and weakening of bones, increasing the risk of fractures. BMD can be measured with a variety of techniques in a variety of sites that are subdivided into central (hip or spine) and peripheral (wrist, finger or heel). Dual x-ray absorptiometry (DXA) is the most commonly used technique for BMD measurements. Ultrasound (US) densitometry is as an office based technology for measuring BMD at peripheral sites, mainly the heel. Peripheral measurements can identify patients with low bone mass, but cannot predict response to pharmacologic therapy and is not a substitute for central BMD measurements. Therefore, central BMD measurements are recommended for the initial diagnosis and for repeat BMD measurements. This policy does not apply to CPT 77078: Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine). Criteria and guidelines can be found on the National Imaging Associates website at http://www.radmd.com/ II. Criteria/Guidelines A. An initial BMD study of the hip and/or spine is covered (subject to Limitations and Administrative Guidelines) to assess fracture risk and the need for pharmacologic therapy in the following individuals considered to be at high-risk for osteoporosis: 1. Women 65 years of age or older and men 70 years of age or older 2. Postmenopausal women with any of the following risk factors: a. History of a low-impact fracture* after age 45 in a first-degree relative b. Body weight of less than 127 lbs. or BMI of 20 or less c. Current smoker d. Surgical or natural menopause before age 40

Bone Mineral Density Studies

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3. Premenopausal women with documented hypo-estrogenic amenorrhea for more than one year 4. Men or women with the following chronic conditions known to be associated with bone loss: a. b. c. d. e. f. g. h. i. j. k. l.

Cushing's syndrome Male hypogonadism for more than five years Hyperthyroidism Hyperparathyroidism Ankylosing spondylitis Rheumatoid arthritis Systemic lupus erythematosus Leukemia Multiple myeloma Chronic kidney disease (stages III, IV and V) Celiac disease Prolonged severe loss of mobility (unable to ambulate outside of one's dwelling without a wheelchair for more than one year)

5. Patients taking any of the following medications associated with bone loss: a. Anticonvulsants b. Oral glucocorticoids for more than three months at a dose equivalent to 5 mg of prednisone or greater per day c. Aromatase inhibitors d. Chemotherapy agents (i.e., methotrexate or other antimetabolites) e. Depo-medroxy progesterone acetate (Depo-Provera) when used for more than two years f. Gonadotropin-releasing hormone (GnRH) agonists (buserelin, leuprolide, nafarelin) 6. Solid organ or allogeneic bone marrow transplant recipients 7. Patients with osseous abnormalities shown on imaging studies indicative of osteoporosis, osteopenia or a vertebral compression fracture (defined as vertebral body height loss of 30% or more) 8. Adults who have had a documented low-impact fracture (excluding fingers and toes) 9. Children with a disease or condition associated with bone loss or on prolonged medications that are known to decrease bone mass B. Peripheral BMD studies are covered (subject to Limitations/Exclusions and Administrative Guidelines) if the hip/spine cannot be done or the patient is over the table limit for weight 

A low-impact fracture is defined as a fracture occurring spontaneously or from a fall from standing height, including fractures from activities such as a cough, sneeze or abrupt movement (e.g., opening a window)

Bone Mineral Density Studies

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III. Limitations/Exclusions A. Routine BMD screening for osteoporosis is not recommended for women under the age of 65 and for men under the age of 70 B. Repeat central BMD studies are limited to one every two years (23 months must past since the previous BMD study) for patients whose last scan showed osteopenia/osteoporosis C. Repeat central BMD studies for individuals who previously tested normal may be retested no sooner than three years from the last BMD if they continue to meet the criteria listed above D. Repeat central BMD studies performed more frequently than once every two years are limited to individuals currently taking an aromatase inhibitor or on glucocorticoid therapy equivalent to 5.0 mg or more of prednisone per day for more than three months E. A follow up DXA is not covered when used to confirm a diagnosis obtained by an US or QCT F. Clinicians are encouraged to use the same facility and same scanner for initial and follow-up BMD studies whenever possible for greater consistency G. Dual Photon Absorptiometry (DPA) and images obtained during a BMD study (e.g., rapid vertebral assessment) are not covered H. 3D reconstruction is not covered for BMD studies IV. Administrative Guidelines A. Precertification is required for the following: 1. Patients under the age of 18. To precertify, please complete HMSA's Precertification Request and mail or fax the form as indicated. The request must include supporting documentation from the patient's medical records with the high-risk indications that would justify a BMD study as well as the proposed therapy for the patient 2. For follow-up studies performed more frequently than once every two years. Requests must include the previous BMD study results, other pertinent test findings and a list of medications the patient is currently taking B. Compliance with the provisions in this policy is subject to monitoring, post payment data analysis, and subsequent medical review. The following documentation should be kept in the patient's medical records and made available upon request: 1. Clinical indications to substantiate that the test is reasonable and necessary 2. Physician’s order signed (not rubber-stamped) and dated (mm/dd/yy) 3. The diagnostic evaluation documenting symptoms, other diagnostic X-rays, and physical exam findings must have been dated at a time reasonably proximate to the scan 4. The name and medication regimen for patients undergoing drug therapy C. If a patient does not meet HMSA’s guidelines for coverage but has indicated that he or she wants the services performed despite noncoverage, the patient should be asked to sign HMSA's Agreement of Financial Responsibility. A signed waiver indicates that the patient will be responsible for the denied charges D. When submitting a claim for a BMD study that does not meet HMSA guidelines, append modifier code GA to the CPT code for the service. The use of the GA modifier will alert HMSA

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that the claim should be processed to indicate that the patient will be financially responsible for the service, and that the noncovered charges should not be a provider adjustment E. The signed waiver should be kept in the patient's record. HMSA reserves the right to conduct periodic audits on claims submitted with the GA modifier and review medical records for signed waivers for this service F. The following codes are provided for informational purposes only. Inclusion/exclusion of a procedure or diagnosis does not constitute or imply coverage or provider reimbursement: Applicable CPT codes: CPT Code

Description

76977

Ultrasound bone density measurement and interpretation, peripheral site(s), any method

77080

Dual energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)

77081

appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Codes that do not meet payment determination criteria: CPT code

Description

77085

Dual-energy x-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment

77086

Vertebral fracture assessment via dual-energy x-ray absorptiometry (DXA)

78350

Bone density (bone mineral content) study, one or more sites; single photon absorptiometry

78351

Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites

HCPCS Code

Description

G0130

Single energy X-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Applicable ICD-10 codes: ICD-10 Code E21.0 E21.1 E21.2 E21.3 E24.0

ICD-10 Name Primary hyperparathyroidism Secondary hyperparathyroidism, not elsewhere classified Other hyperparathyroidism Hyperparathyroidism, unspecified Pituitary-dependent Cushing's disease

Bone Mineral Density Studies

E24.2 E24.3 E24.4 E24.8 E24.9 E28.310 E28.319 E28.39 E89.40 E89.41 G40.001

G40.009

G40.011

G40.019

G40.101

G40.109

G40.111 G40.119

G40.201

G40.209

G40.211

G40.219

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Drug-induced Cushing's syndrome Ectopic ACTH syndrome Alcohol-induced pseudo-Cushing's syndrome Other Cushing's syndrome Cushing's syndrome, unspecified Symptomatic premature menopause Asymptomatic premature menopause Other primary ovarian failure Asymptomatic postprocedural ovarian failure Symptomatic postprocedural ovarian failure Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus Localization-related (focal) (partial) symptomatic epilepsy and epileptic

Bone Mineral Density Studies

G40.301 G40.309 G40.311 G40.319 G40.401 G40.409 G40.411 G40.419 G40.501 G40.509 G40.801 G40.802 G40.803 G40.804 G40.811 G40.812 G40.813 G40.814 G40.821 G40.822 G40.823 G40.824 G40.89 G40.901 G40.909 G40.911 G40.919 G40.A01 G40.A09 G40.A11

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syndromes with complex partial seizures, intractable, without status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus Epileptic seizures related to external causes, not intractable, with status epilepticus Epileptic seizures related to external causes, not intractable, without status epilepticus Other epilepsy, not intractable, with status epilepticus Other epilepsy, not intractable, without status epilepticus Other epilepsy, intractable, with status epilepticus Other epilepsy, intractable, without status epilepticus Lennox-Gastaut syndrome, not intractable, with status epilepticus Lennox-Gastaut syndrome, not intractable, without status epilepticus Lennox-Gastaut syndrome, intractable, with status epilepticus Lennox-Gastaut syndrome, intractable, without status epilepticus Epileptic spasms, not intractable, with status epilepticus Epileptic spasms, not intractable, without status epilepticus Epileptic spasms, intractable, with status epilepticus Epileptic spasms, intractable, without status epilepticus Other seizures Epilepsy, unspecified, not intractable, with status epilepticus Epilepsy, unspecified, not intractable, without status epilepticus Epilepsy, unspecified, intractable, with status epilepticus Epilepsy, unspecified, intractable, without status epilepticus Absence epileptic syndrome, not intractable, with status epilepticus Absence epileptic syndrome, not intractable, without status epilepticus Absence epileptic syndrome, intractable, with status epilepticus

Bone Mineral Density Studies

G40.A19 G40.B01 G40.B09 G40.B11 G40.B19 K90.0 M05.40 M05.411 M05.412 M05.419 M05.421 M05.422 M05.429 M05.431 M05.432 M05.439 M05.441 M05.442 M05.449 M05.451 M05.452 M05.459 M05.461 M05.462 M05.469 M05.471 M05.472 M05.479 M05.49 M05.50 M05.511 M05.512 M05.519 M05.521 M05.522 M05.529 M05.531 M05.532 M05.539

7

Absence epileptic syndrome, intractable, without status epilepticus Juvenile myoclonic epilepsy, not intractable, with status epilepticus Juvenile myoclonic epilepsy, not intractable, without status epilepticus Juvenile myoclonic epilepsy, intractable, with status epilepticus Juvenile myoclonic epilepsy, intractable, without status epilepticus Celiac disease Rheumatoid myopathy with rheumatoid arthritis of unspecified site Rheumatoid myopathy with rheumatoid arthritis of right shoulder Rheumatoid myopathy with rheumatoid arthritis of left shoulder Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder Rheumatoid myopathy with rheumatoid arthritis of right elbow Rheumatoid myopathy with rheumatoid arthritis of left elbow Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow Rheumatoid myopathy with rheumatoid arthritis of right wrist Rheumatoid myopathy with rheumatoid arthritis of left wrist Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist Rheumatoid myopathy with rheumatoid arthritis of right hand Rheumatoid myopathy with rheumatoid arthritis of left hand Rheumatoid myopathy with rheumatoid arthritis of unspecified hand Rheumatoid myopathy with rheumatoid arthritis of right hip Rheumatoid myopathy with rheumatoid arthritis of left hip Rheumatoid myopathy with rheumatoid arthritis of unspecified hip Rheumatoid myopathy with rheumatoid arthritis of right knee Rheumatoid myopathy with rheumatoid arthritis of left knee Rheumatoid myopathy with rheumatoid arthritis of unspecified knee Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot Rheumatoid myopathy with rheumatoid arthritis of multiple sites Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist

Bone Mineral Density Studies

M05.541 M05.542 M05.549 M05.551 M05.552 M05.559 M05.561 M05.562 M05.569 M05.571 M05.572 M05.579 M05.59 M05.70 M05.711 M05.712 M05.719 M05.721 M05.722 M05.729 M05.731 M05.732 M05.739 M05.741 M05.742 M05.749 M05.751

8

Rheumatoid polyneuropathy with rheumatoid arthritis of right hand Rheumatoid polyneuropathy with rheumatoid arthritis of left hand Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand Rheumatoid polyneuropathy with rheumatoid arthritis of right hip Rheumatoid polyneuropathy with rheumatoid arthritis of left hip Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip Rheumatoid polyneuropathy with rheumatoid arthritis of right knee Rheumatoid polyneuropathy with rheumatoid arthritis of left knee Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement

Bone Mineral Density Studies

M05.752 M05.759 M05.761 M05.762 M05.769 M05.771 M05.772 M05.779 M05.79 M05.80 M05.811 M05.812 M05.819 M05.821 M05.822 M05.829 M05.831 M05.832 M05.839 M05.841 M05.842 M05.849 M05.851 M05.852 M05.859 M05.861 M05.862 M05.869 M05.871 M05.872 M05.879 M05.89

9

Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement Other rheumatoid arthritis with rheumatoid factor of unspecified site Other rheumatoid arthritis with rheumatoid factor of right shoulder Other rheumatoid arthritis with rheumatoid factor of left shoulder Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder Other rheumatoid arthritis with rheumatoid factor of right elbow Other rheumatoid arthritis with rheumatoid factor of left elbow Other rheumatoid arthritis with rheumatoid factor of unspecified elbow Other rheumatoid arthritis with rheumatoid factor of right wrist Other rheumatoid arthritis with rheumatoid factor of left wrist Other rheumatoid arthritis with rheumatoid factor of unspecified wrist Other rheumatoid arthritis with rheumatoid factor of right hand Other rheumatoid arthritis with rheumatoid factor of left hand Other rheumatoid arthritis with rheumatoid factor of unspecified hand Other rheumatoid arthritis with rheumatoid factor of right hip Other rheumatoid arthritis with rheumatoid factor of left hip Other rheumatoid arthritis with rheumatoid factor of unspecified hip Other rheumatoid arthritis with rheumatoid factor of right knee Other rheumatoid arthritis with rheumatoid factor of left knee Other rheumatoid arthritis with rheumatoid factor of unspecified knee Other rheumatoid arthritis with rheumatoid factor of right ankle and foot Other rheumatoid arthritis with rheumatoid factor of left ankle and foot Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot Other rheumatoid arthritis with rheumatoid factor of multiple sites

Bone Mineral Density Studies

M05.9 M06.00 M06.011 M06.012 M06.019 M06.021 M06.022 M06.029 M06.031 M06.032 M06.039 M06.041 M06.042 M06.042 M06.049 M06.051 M06.052 M06.059 M06.061 M06.062 M06.069 M06.071 M06.072 M06.079 M06.08 M06.09 M06.20 M06.211 M06.212 M06.219 M06.221 M06.222 M06.229 M06.231 M06.232 M06.239 M06.241 M06.242

10

Rheumatoid arthritis with rheumatoid factor, unspecified Rheumatoid arthritis without rheumatoid factor, unspecified site Rheumatoid arthritis without rheumatoid factor, right shoulder Rheumatoid arthritis without rheumatoid factor, left shoulder Rheumatoid arthritis without rheumatoid factor, unspecified shoulder Rheumatoid arthritis without rheumatoid factor, right elbow Rheumatoid arthritis without rheumatoid factor, left elbow Rheumatoid arthritis without rheumatoid factor, unspecified elbow Rheumatoid arthritis without rheumatoid factor, right wrist Rheumatoid arthritis without rheumatoid factor, left wrist Rheumatoid arthritis without rheumatoid factor, unspecified wrist Rheumatoid arthritis without rheumatoid factor, right hand Rheumatoid arthritis without rheumatoid factor, left hand Rheumatoid arthritis without rheumatoid factor, left hand Rheumatoid arthritis without rheumatoid factor, unspecified hand Rheumatoid arthritis without rheumatoid factor, right hip Rheumatoid arthritis without rheumatoid factor, left hip Rheumatoid arthritis without rheumatoid factor, unspecified hip Rheumatoid arthritis without rheumatoid factor, right knee Rheumatoid arthritis without rheumatoid factor, left knee Rheumatoid arthritis without rheumatoid factor, unspecified knee Rheumatoid arthritis without rheumatoid factor, right ankle and foot Rheumatoid arthritis without rheumatoid factor, left ankle and foot Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot Rheumatoid arthritis without rheumatoid factor, vertebrae Rheumatoid arthritis without rheumatoid factor, multiple sites Rheumatoid bursitis, unspecified site Rheumatoid bursitis, right shoulder Rheumatoid bursitis, left shoulder Rheumatoid bursitis, unspecified shoulder Rheumatoid bursitis, right elbow Rheumatoid bursitis, left elbow Rheumatoid bursitis, unspecified elbow Rheumatoid bursitis, right wrist Rheumatoid bursitis, left wrist Rheumatoid bursitis, unspecified wrist Rheumatoid bursitis, right hand Rheumatoid bursitis, left hand

Bone Mineral Density Studies

M06.249 M06.251 M06.252 M06.259 M06.261 M06.262 M06.269 M06.271 M06.272 M06.279 M06.28 M06.29 M06.30 M06.311 M06.312 M06.319 M06.321 M06.322 M06.329 M06.331 M06.332 M06.339 M06.341 M06.342 M06.349 M06.351 M06.352 M06.359 M06.361 M06.362 M06.369 M06.371 M06.372 M06.379 M06.38 M06.39 M06.80

Rheumatoid bursitis, unspecified hand Rheumatoid bursitis, right hip Rheumatoid bursitis, left hip Rheumatoid bursitis, unspecified hip Rheumatoid bursitis, right knee Rheumatoid bursitis, left knee Rheumatoid bursitis, unspecified knee Rheumatoid bursitis, right ankle and foot Rheumatoid bursitis, left ankle and foot Rheumatoid bursitis, unspecified ankle and foot Rheumatoid bursitis, vertebrae Rheumatoid bursitis, multiple sites Rheumatoid nodule, unspecified site Rheumatoid nodule, right shoulder Rheumatoid nodule, left shoulder Rheumatoid nodule, unspecified shoulder Rheumatoid nodule, right elbow Rheumatoid nodule, left elbow Rheumatoid nodule, unspecified elbow Rheumatoid nodule, right wrist Rheumatoid nodule, left wrist Rheumatoid nodule, unspecified wrist Rheumatoid nodule, right hand Rheumatoid nodule, left hand Rheumatoid nodule, unspecified hand Rheumatoid nodule, right hip Rheumatoid nodule, left hip Rheumatoid nodule, unspecified hip Rheumatoid nodule, right knee Rheumatoid nodule, left knee Rheumatoid nodule, unspecified knee Rheumatoid nodule, right ankle and foot Rheumatoid nodule, left ankle and foot Rheumatoid nodule, unspecified ankle and foot Rheumatoid nodule, vertebrae Rheumatoid nodule, multiple sites Other specified rheumatoid arthritis, unspecified site

11

Bone Mineral Density Studies

M06.811 M06.812 M06.819 M06.821 M06.822 M06.829 M06.831 M06.832 M06.839 M06.841 M06.842 M06.849 M06.851 M06.852 M06.859 M06.861 M06.862 M06.869 M06.871 M06.872 M06.879 M06.88 M06.89 M06.9 M08.1 M32.0 M32.10 M32.11 M32.12 M32.13 M32.14 M32.15 M32.19 M32.8 M32.9 M45.0 M45.1

12

Other specified rheumatoid arthritis, right shoulder Other specified rheumatoid arthritis, left shoulder Other specified rheumatoid arthritis, unspecified shoulder Other specified rheumatoid arthritis, right elbow Other specified rheumatoid arthritis, left elbow Other specified rheumatoid arthritis, unspecified elbow Other specified rheumatoid arthritis, right wrist Other specified rheumatoid arthritis, left wrist Other specified rheumatoid arthritis, unspecified wrist Other specified rheumatoid arthritis, right hand Other specified rheumatoid arthritis, left hand Other specified rheumatoid arthritis, unspecified hand Other specified rheumatoid arthritis, right hip Other specified rheumatoid arthritis, left hip Other specified rheumatoid arthritis, unspecified hip Other specified rheumatoid arthritis, right knee Other specified rheumatoid arthritis, left knee Other specified rheumatoid arthritis, unspecified knee Other specified rheumatoid arthritis, right ankle and foot Other specified rheumatoid arthritis, left ankle and foot Other specified rheumatoid arthritis, unspecified ankle and foot Other specified rheumatoid arthritis, vertebrae Other specified rheumatoid arthritis, multiple sites Rheumatoid arthritis, unspecified Juvenile ankylosing spondylitis Drug-induced systemic lupus erythematosus Systemic lupus erythematosus, organ or system involvement unspecified Endocarditis in systemic lupus erythematosus Pericarditis in systemic lupus erythematosus Lung involvement in systemic lupus erythematosus Glomerular disease in systemic lupus erythematosus Tubulo-interstitial nephropathy in systemic lupus erythematosus Other organ or system involvement in systemic lupus erythematosus Other forms of systemic lupus erythematosus Systemic lupus erythematosus, unspecified Ankylosing spondylitis of multiple sites in spine Ankylosing spondylitis of occipito-atlanto-axial region

Bone Mineral Density Studies

M45.2 M45.3 M45.4 M45.5 M45.6 M45.7 M45.8 M45.9 M48.8x1 M48.8x2 M48.8x3 M48.8x4 M48.8x5 M48.8x6 M48.8x7 M48.8x8 M48.8x9 M80.00xA M80.00xD M80.00xG M80.00xK M80.00xP M80.00xS M80.031A M80.031D M80.031G M80.031K

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Ankylosing spondylitis of cervical region Ankylosing spondylitis of cervicothoracic region Ankylosing spondylitis of thoracic region Ankylosing spondylitis of thoracolumbar region Ankylosing spondylitis lumbar region Ankylosing spondylitis of lumbosacral region Ankylosing spondylitis sacral and sacrococcygeal region Ankylosing spondylitis of unspecified sites in spine Other specified spondylopathies, occipito-atlanto-axial region Other specified spondylopathies, cervical region Other specified spondylopathies, cervicothoracic region Other specified spondylopathies, thoracic region Other specified spondylopathies, thoracolumbar region Other specified spondylopathies, lumbar region Other specified spondylopathies, lumbosacral region Other specified spondylopathies, sacral and sacrococcygeal region Other specified spondylopathies, site unspecified Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with delayed healing Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with nonunion Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with malunion Age-related osteoporosis with current pathological fracture, unspecified site, sequela Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture Age-related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with routine healing Age-related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with delayed healing Age-related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with nonunion

Bone Mineral Density Studies

M80.031P M80.031S M80.032A M80.032D M80.032G M80.032K M80.032P M80.032S M80.039A M80.039D M80.039G M80.039K M80.039P M80.039S M80.80xA M80.80xD M80.80xG M80.80xK M80.80xP

14

Age-related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with malunion Age-related osteoporosis with current pathological fracture, right forearm, sequela Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture Age-related osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with routine healing Age-related osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with delayed healing Age-related osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with nonunion Age-related osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with malunion Age-related osteoporosis with current pathological fracture, left forearm, sequela Age-related osteoporosis with current pathological fracture, unspecified forearm, initial encounter for fracture Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with routine healing Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with delayed healing Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with nonunion Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with malunion Age-related osteoporosis with current pathological fracture, unspecified forearm, sequela Other osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture Other osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing Other osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with delayed healing Other osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with nonunion Other osteoporosis with current pathological fracture, unspecified site,

Bone Mineral Density Studies

M80.80xS M80.831A M80.831D M80.831G M80.831K M80.831P M80.831S M80.832A M80.832D M80.832G M80.832K M80.832P M80.832S M80.839A M80.839D M80.839G M80.839K M80.839P M80.839S

15

subsequent encounter for fracture with malunion Other osteoporosis with current pathological fracture, unspecified site, sequela Other osteoporosis with current pathological fracture, right forearm, initial encounter for fracture Other osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with routine healing Other osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with delayed healing Other osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with nonunion Other osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with malunion Other osteoporosis with current pathological fracture, right forearm, sequela Other osteoporosis with current pathological fracture, left forearm, initial encounter for fracture Other osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with routine healing Other osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with delayed healing Other osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with nonunion Other osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with malunion Other osteoporosis with current pathological fracture, left forearm, sequela Other osteoporosis with current pathological fracture, unspecified forearm, initial encounter for fracture Other osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with routine healing Other osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with delayed healing Other osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with nonunion Other osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with malunion Other osteoporosis with current pathological fracture, unspecified forearm,

Bone Mineral Density Studies

M81.0 M81.6 M81.8 M84.40xA M84.40xD M84.40xG M84.40xK M84.40xP M84.40xS M84.431A M84.431D M84.431G M84.431K M84.431P M84.431S M84.432A M84.432D M84.432G M84.432K M84.432P M84.432S M84.433A M84.433D

16

sequela Age-related osteoporosis without current pathological fracture Localized osteoporosis [Lequesne] Other osteoporosis without current pathological fracture Pathological fracture, unspecified site, initial encounter for fracture Pathological fracture, unspecified site, subsequent encounter for fracture with routine healing Pathological fracture, unspecified site, subsequent encounter for fracture with delayed healing Pathological fracture, unspecified site, subsequent encounter for fracture with nonunion Pathological fracture, unspecified site, subsequent encounter for fracture with malunion Pathological fracture, unspecified site, sequela Pathological fracture, right ulna, initial encounter for fracture Pathological fracture, right ulna, subsequent encounter for fracture with routine healing Pathological fracture, right ulna, subsequent encounter for fracture with delayed healing Pathological fracture, right ulna, subsequent encounter for fracture with nonunion Pathological fracture, right ulna, subsequent encounter for fracture with malunion Pathological fracture, right ulna, sequela Pathological fracture, left ulna, initial encounter for fracture Pathological fracture, left ulna, subsequent encounter for fracture with routine healing Pathological fracture, left ulna, subsequent encounter for fracture with delayed healing Pathological fracture, left ulna, subsequent encounter for fracture with nonunion Pathological fracture, left ulna, subsequent encounter for fracture with malunion Pathological fracture, left ulna, sequela Pathological fracture, right radius, initial encounter for fracture Pathological fracture, right radius, subsequent encounter for fracture with routine healing

Bone Mineral Density Studies

M84.433G M84.433K M84.433P M84.433S M84.434A M84.434D M84.434G M84.434K M84.434P M84.434S M84.439K M84.439P M84.439S M84.50xA M84.50xD M84.50xG M84.50xK M84.50xP M84.50xS M84.531A M84.531D

17

Pathological fracture, right radius, subsequent encounter for fracture with delayed healing Pathological fracture, right radius, subsequent encounter for fracture with nonunion Pathological fracture, right radius, subsequent encounter for fracture with malunion Pathological fracture, right radius, sequela Pathological fracture, left radius, initial encounter for fracture Pathological fracture, left radius, subsequent encounter for fracture with routine healing Pathological fracture, left radius, subsequent encounter for fracture with delayed healing Pathological fracture, left radius, subsequent encounter for fracture with nonunion Pathological fracture, left radius, subsequent encounter for fracture with malunion Pathological fracture, left radius, sequela Pathological fracture, unspecified ulna and radius, subsequent encounter for fracture with nonunion Pathological fracture, unspecified ulna and radius, subsequent encounter for fracture with malunion Pathological fracture, unspecified ulna and radius, sequela Pathological fracture in neoplastic disease, unspecified site, initial encounter for fracture Pathological fracture in neoplastic disease, unspecified site, subsequent encounter for fracture with routine healing Pathological fracture in neoplastic disease, unspecified site, subsequent encounter for fracture with delayed healing Pathological fracture in neoplastic disease, unspecified site, subsequent encounter for fracture with nonunion Pathological fracture in neoplastic disease, unspecified site, subsequent encounter for fracture with malunion Pathological fracture in neoplastic disease, unspecified site, sequela Pathological fracture in neoplastic disease, right ulna, initial encounter for fracture Pathological fracture in neoplastic disease, right ulna, subsequent encounter for fracture with routine healing

Bone Mineral Density Studies

M84.531G M84.531K M84.531P M84.531S M84.532A M84.532D M84.532G M84.532K M84.532P M84.532S M84.533A M84.533D M84.533G M84.533K M84.533P M84.533S M84.534A M84.534D M84.534G M84.534K

18

Pathological fracture in neoplastic disease, right ulna, subsequent encounter for fracture with delayed healing Pathological fracture in neoplastic disease, right ulna, subsequent encounter for fracture with nonunion Pathological fracture in neoplastic disease, right ulna, subsequent encounter for fracture with malunion Pathological fracture in neoplastic disease, right ulna, sequela Pathological fracture in neoplastic disease, left ulna, initial encounter for fracture Pathological fracture in neoplastic disease, left ulna, subsequent encounter for fracture with routine healing Pathological fracture in neoplastic disease, left ulna, subsequent encounter for fracture with delayed healing Pathological fracture in neoplastic disease, left ulna, subsequent encounter for fracture with nonunion Pathological fracture in neoplastic disease, left ulna, subsequent encounter for fracture with malunion Pathological fracture in neoplastic disease, left ulna, sequela Pathological fracture in neoplastic disease, right radius, initial encounter for fracture Pathological fracture in neoplastic disease, right radius, subsequent encounter for fracture with routine healing Pathological fracture in neoplastic disease, right radius, subsequent encounter for fracture with delayed healing Pathological fracture in neoplastic disease, right radius, subsequent encounter for fracture with nonunion Pathological fracture in neoplastic disease, right radius, subsequent encounter for fracture with malunion Pathological fracture in neoplastic disease, right radius, sequela Pathological fracture in neoplastic disease, left radius, initial encounter for fracture Pathological fracture in neoplastic disease, left radius, subsequent encounter for fracture with routine healing Pathological fracture in neoplastic disease, left radius, subsequent encounter for fracture with delayed healing Pathological fracture in neoplastic disease, left radius, subsequent encounter for fracture with nonunion

Bone Mineral Density Studies

M84.534P M84.534S M84.539A M84.539D M84.539G M84.539K M84.539P M84.539S M84.60xA M84.60xD M84.60xG M84.60xK M84.60xP M84.60xS M84.631A M84.631D M84.631G M84.631K M84.631P M84.631S

19

Pathological fracture in neoplastic disease, left radius, subsequent encounter for fracture with malunion Pathological fracture in neoplastic disease, left radius, sequela Pathological fracture in neoplastic disease, unspecified ulna and radius, initial encounter for fracture Pathological fracture in neoplastic disease, unspecified ulna and radius, subsequent encounter for fracture with routine healing Pathological fracture in neoplastic disease, unspecified ulna and radius, subsequent encounter for fracture with delayed healing Pathological fracture in neoplastic disease, unspecified ulna and radius, subsequent encounter for fracture with nonunion Pathological fracture in neoplastic disease, unspecified ulna and radius, subsequent encounter for fracture with malunion Pathological fracture in neoplastic disease, unspecified ulna and radius, sequela Pathological fracture in other disease, unspecified site, initial encounter for fracture Pathological fracture in other disease, unspecified site, subsequent encounter for fracture with routine healing Pathological fracture in other disease, unspecified site, subsequent encounter for fracture with delayed healing Pathological fracture in other disease, unspecified site, subsequent encounter for fracture with nonunion Pathological fracture in other disease, unspecified site, subsequent encounter for fracture with malunion Pathological fracture in other disease, unspecified site, sequela Pathological fracture in other disease, right ulna, initial encounter for fracture Pathological fracture in other disease, right ulna, subsequent encounter for fracture with routine healing Pathological fracture in other disease, right ulna, subsequent encounter for fracture with delayed healing Pathological fracture in other disease, right ulna, subsequent encounter for fracture with nonunion Pathological fracture in other disease, right ulna, subsequent encounter for fracture with malunion Pathological fracture in other disease, right ulna, sequela

Bone Mineral Density Studies

M84.632A M84.632D M84.632G M84.632K M84.632P M84.632S M84.633A M84.633D M84.633G M84.633K M84.633P M84.633S M84.634A M84.634D M84.634G M84.634K M84.634P M84.634S M84.639A M84.639D

20

Pathological fracture in other disease, left ulna, initial encounter for fracture Pathological fracture in other disease, left ulna, subsequent encounter for fracture with routine healing Pathological fracture in other disease, left ulna, subsequent encounter for fracture with delayed healing Pathological fracture in other disease, left ulna, subsequent encounter for fracture with nonunion Pathological fracture in other disease, left ulna, subsequent encounter for fracture with malunion Pathological fracture in other disease, left ulna, sequela Pathological fracture in other disease, right radius, initial encounter for fracture Pathological fracture in other disease, right radius, subsequent encounter for fracture with routine healing Pathological fracture in other disease, right radius, subsequent encounter for fracture with delayed healing Pathological fracture in other disease, right radius, subsequent encounter for fracture with nonunion Pathological fracture in other disease, right radius, subsequent encounter for fracture with malunion Pathological fracture in other disease, right radius, sequela Pathological fracture in other disease, left radius, initial encounter for fracture Pathological fracture in other disease, left radius, subsequent encounter for fracture with routine healing Pathological fracture in other disease, left radius, subsequent encounter for fracture with delayed healing Pathological fracture in other disease, left radius, subsequent encounter for fracture with nonunion Pathological fracture in other disease, left radius, subsequent encounter for fracture with malunion Pathological fracture in other disease, left radius, sequela Pathological fracture in other disease, unspecified ulna and radius, initial encounter for fracture Pathological fracture in other disease, unspecified ulna and radius, subsequent encounter for fracture with routine healing

Bone Mineral Density Studies

M84.639G M84.639K M84.639P M84.639S M85.80 – M85.89 M85.9 M89.9 M94.9 N18.3 N18.4 N18.5 N25.81 N91.0 N91.1 N91.2 N91.3 N91.4 N91.5 N95.1 N95.2 N95.8 N95.9 T38.0x5A T38.0x5S T38.4x5A T38.4x5S T38.5x5A T38.5x5S T50.0x5A T50.0x5S Z08 Z09

21

Pathological fracture in other disease, unspecified ulna and radius, subsequent encounter for fracture with delayed healing Pathological fracture in other disease, unspecified ulna and radius, subsequent encounter for fracture with nonunion Pathological fracture in other disease, unspecified ulna and radius, subsequent encounter for fracture with malunion Pathological fracture in other disease, unspecified ulna and radius, sequela Other specified disorders of bone density and structure Disorder of bone density and structure, unspecified Disorder of bone, unspecified Disorder of cartilage, unspecified Chronic kidney disease, stage 3 (moderate) Chronic kidney disease, stage 4 (severe) Chronic kidney disease, stage 5 Secondary hyperparathyroidism of renal origin Primary amenorrhea Secondary amenorrhea Amenorrhea, unspecified Primary oligomenorrhea Secondary oligomenorrhea Oligomenorrhea, unspecified Menopausal and female climacteric states Postmenopausal atrophic vaginitis Other specified menopausal and perimenopausal disorders Unspecified menopausal and perimenopausal disorder Adverse effect of glucocorticoids and synthetic analogues, initial encounter Adverse effect of glucocorticoids and synthetic analogues, sequela Adverse effect of oral contraceptives, initial encounter Adverse effect of oral contraceptives, sequela Adverse effect of other estrogens and progestogens, initial encounter Adverse effect of other estrogens and progestogens, sequela Adverse effect of mineralocorticoids and their antagonists, initial encounter Adverse effect of mineralocorticoids and their antagonists, sequela Encounter for follow-up examination after completed treatment for malignant neoplasm Encounter for follow-up examination after completed treatment for

Bone Mineral Density Studies

Z13.820 Z78.0 Z79.3 Z79.51 Z79.52 Z79.891 Z79.899

22

conditions other than malignant neoplasm Encounter for screening for osteoporosis Asymptomatic menopausal state Long term (current) use of hormonal contraceptives Long term (current) use of inhaled steroids Long term (current) use of systemic steroids Long term (current) use of opiate analgesic Other long term (current) drug therapy

V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii's Patients' Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA's determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation. VI. References 1. Watts NB, Bilezikian JP, Camacho PM, Greenspan SL, Harris ST, Hodgson SF, Kleerekoper M, Luckey MM, McClung MR, Pollack RP, Petak SM, AACE Osteoporosis Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis. Endocr Pract. 2010 Nov-Dec; 16(Suppl 3):1-37. 2. BCBSA Medical Policy Reference Manual. Bone density studies. Policy #6.01.01. Last review March 2014 2015 3. Diagnosis of Osteoporosis in Men, Premenopausal Women, and Children. J Clin Densitom 2004 Spring; 7(1):17-26. [82 references]

Bone Mineral Density Studies

23

4. Hau Liu, Neil M. Paige, et.al: Screening for osteoporosis in men: A systematic review from the American College of Physicians Guideline. Ann Intern Med, May 2008; 148: 685-701. 5. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline, Diagnosis and Treatment of Osteoporosis. Eighth Edition July 2013 6. National Osteoporosis Foundation: Clinicians Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2014. 7. U.S. Preventive Services Task Force. Screening for Osteoporosis. Recommendation Statement. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. 8. Ward L, et al; Bisphosphonate Therapy for Children and Adolescents with Secondary Osteoporosis. Premedline identifier 17943849. Cochrane database sys rev. 2007. 9. Conference of Radiation Control Program Directors' Task Force on Bone Densitometry. Technical white paper: Bone Densitometry. October 2006. 10. Adams J et al. Vertebral Fracture Initiative Part II Radiological Assessment of Vertebral Fracture. International Osteoporosis Foundation. 1-49. 11. World Health Organization Collaborating Centre for Metabolic Bone Diseases. WHO Fracture Risk Assessment tool. Available online at http://www.shef.ac.uk/FRAX/tool.jsp