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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 say that an estrogen-deficient woman qualifies for a bone mineral density study if she is at clinical 
risk for osteoporosis, based on her medical history and other findings. Unless this applies and is documented in 
the medical record, the service is not covered. In addition to gender and estrogen-deficiency, pertinent factors 
acceptable as documentation for the clinical risk include, but are not limited to: age, family history and 
personal history of fractures as an adult, race, bone structure and body weight, premature menopause, lifestyle, 
medications, chronic diseases, and other genetic and environmental factors. Symptoms and findings of 
osteoporosis include, but are not limited to: back pain, loss of height, curving spine, and chest x-ray showing 
osteopenia. You can find this rule in the Local Coverage Determination (LCD) - Bone Mineral Density Studies 
(L36356). 
 
The rules say that bone density measurement is not a covered Medicare benefit when utilized for osteoporosis 
screening in an estrogen-deficient woman, who has not been determined by the physician or a qualified 
nonphysician practitioner treating her to be at clinical risk for osteoporosis, based on her medical history and 
other findings. If - in addition to gender and estrogen-deficiency - a woman has been determined to be at 
clinical risk for osteoporosis, based on her history and other findings, and this has been appropriately 
documented in the medical record, this Contractor will interpret the menopausal state as symptomatic. You can 
find this rule in the Local Coverage Determination (LCD) - Bone Mineral Density Studies (L36356). 
 
The rules say that the coverage criteria for bone mass measurements are: 
 
1. There must be an order by the individuals physician or qualified nonphysician practitioner treating the 
patient following an evaluation of the need for a measurement, including a determination as to the medically 
appropriate measurement to be used for the individual. A physician or qualified nonphysician practitioner 
treating the beneficiary for purposes of this provision is one who furnishes a consultation or treats a beneficiary 
for a specific medical problem and who uses the results in the management of the patient. For the purpose of the bone mass measurement benefit, qualified nonphysician practitioners include physician assistants, nurse 
practitioners, clinical nurse specialists and certified nurse midwives. 
2. This service must be furnished by a qualified supplier or provider of such services under the appropriate 
level of physician supervision as defined in CFR 410.32(b); 
3. This service must be reasonable and necessary for diagnosing, treating, or monitoring a qualified individual 
as defined above; and 
4. This service is a radiologic or radioisotopic procedure which must be performed with a bone densitometer or 
a bone sonometer system cleared for marketing by the FDA, under 21 CFR part 807 or approved for marketing 
under 21 CFR part 814 for identifying bone mass or detecting bone loss or determining bone quality, with the 
exception of dual photon absorptiometry devices. 
 
You can find this rule in the Local Coverage Determination (LCD) - Bone Mineral Density Studies (L36356). 
 
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.