Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that: 
 
1. Tests not ordered by the physician/qualified non-physician practitioner, who is treating the beneficiary, are 
not reasonable and necessary. 
 
2. Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of 
sites studied (e.g., if the spine and hip are studied, CPT code 77080 should be billed only once). 
 
3. It is not medically necessary to perform more than one type of BMM test in any individual, unless a 
DXA confirmatory test is performed as a baseline for future monitoring (see Indications #7 and #8). 
 
4. It is not medically necessary to have both peripheral and axial BMM tests performed on the same day. 
 
5. Medicare will not reimburse BMM tests performed by a second provider, when a test has already been 
performed within the defined coverage period, as stated above, unless as confirmatory testing for future 
monitoring. Beneficiaries must authorize providers to obtain prior test results. If unsuccessful efforts to 
obtain prior test results from another provider are documented, new tests may be considered for 
reimbursement. 
 
6. Single and dual photon absorptiometry, CPT code 78350 and 78351, are non-covered services. 
 
7. Bone mass measurement is not covered under the portable x-ray benefit and will be denied when 
performed by a portable x-ray supplier. Transportation charges for BMM testing are not covered. 
 
8. Bone mass measurement tests provided without an accompanying interpretation and report, as part of 
the test, will be denied as not medically necessary. The report must be separate and distinct from an evaluation 
and management note/record. 
 
9. CPT code 77082 is considered by Medicare to represent vertebral fracture assessment only. Because 
code 77082 does not represent a Bone Density Study it should NOT be billed for screening. This code 
may be billed when medically necessary (i.e. when a vertebral fracture assessment is required). 
Symptoms should be present and documented, and it should be anticipated that the results of the test will be used in the management of the patient. You can find this rule at the Medicare Local Coverage Article 
(LCA), A57132, Billing and Coding: Bone Mass Measurement. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that the Plan covers bone mass measurement. For qualified individuals (generally, this 
means people at risk of losing bone mass or at risk of osteoporosis), the following services are covered every 
24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or 
determine bone quality, including a physicians interpretation of the results. You can find this information on 
page 68 of the Plan's 2022 Evidence of Coverage.