Bone mass measurement (BMM) studies are _radiologic, radioisotopic or other
procedures that meet all of the following conditions:_

  * quantify bone mineral density, detect bone loss or determine bone quality;
  * are performed with either a bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under 21 CFR part 814;
  * include a physician's interpretation of the results.

The following procedures are used to measure bone mineral density:

  * dual energy x-ray absorptiometry (DXA);
  * radiographic absorptiometry (RA);
  * bone sonometry (ultrasound);
  * single energy x-ray absorptiometry (SEXA); and
  * quantitative computed tomography (QCT).

**Indications** :

Medicare will cover a bone mass measurement test when it meets all of the
following criteria:

1\. It is performed with 1 of the covered tests listed above.

2\. It is performed on a qualified individual for the purpose of identifying
bone mass, detecting bone loss or determining bone quality. The term
"qualified individual" means an individual who meets the medical indications
for at least 1 of the 5 categories listed below:

  * A woman who has been determined by the physician or a qualified non-physician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings;
  * An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture;
  * An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of prednisone, or greater, per day, for more than 3 months;
  * An individual with primary hyperparathyroidism;
  * An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

3\. It is furnished by a qualified supplier or provider of such services under
at least the general level of supervision of a physician as defined in 42 CFR
410.32(b).

4\. The test is ordered by the individual's physician or qualified non-
physician practitioner, who is treating the beneficiary following an
evaluation of the need for the measurement, including a determination as to
the medically appropriate measurement to be used for the individual, and who
uses the results in the management of the patient.

5\. The test is reasonable and necessary for diagnosing, treating, or
monitoring of a "qualified individual" as defined above in #2. Monitoring is
defined as subsequent testing in patients on FDA-approved drug therapy.

6\. Medicare may cover a bone mass measurement for a beneficiary once every 2
years (if at least 23 months have passed since the month the last bone mass
measurement was performed).

7\. For conditions specified, Medicare will cover a bone mass measurement for
a qualified beneficiary more frequently than every 2 years, if medically
necessary for the diagnosis or treatment of the patient and if related to the
condition listed. In these instances, payment may be made for tests performed
after 11 months have elapsed since the previous bone mass measurement test.
Examples include, but are not limited to, the following medical
circumstance(s):

  * _Monitoring beneficiaries on long-term glucocorticoid (5 mg/day) therapy of more than 3 months (patients must be on glucocorticoids for greater than 3 months duration, but BMM monitoring is at yearly intervals)._
  * _Confirming baseline BMMs to permit monitoring of beneficiaries in the future._

_In addition, BMM for the following may be reimbursed more frequently than
every 2 years:_

  * Follow up bone mineral density testing to assess FDA-approved osteoporosis drug therapy until a response to such therapy has been documented over time.

8\. A confirmatory baseline BMM is only covered when it is performed with a
dual-energy x-ray absorptiometry system (axial skeleton) and the initial BMM
was not performed by a dual-energy x-ray absorptiometry system (axial
skeleton).

A confirmatory baseline BMM is not covered if the initial BMM was performed by
a dual-energy x-ray absorptiometry system (axial skeleton).

9\. For an individual being monitored to assess the response to, or efficacy
of, an FDA-approved osteoporosis drug therapy, the test is only covered if it
is performed with a dual-energy x-ray absorptiometry system (axial skeleton).

10\. The test must include a physician's interpretation of the results.

11\. Since not every woman who has been prescribed estrogen replacement
therapy (ERT) may be receiving an "adequate" dose of the therapy, the fact
that a woman is receiving ERT should not preclude her treating physician/other
qualified non-physician practitioner from ordering a bone mass measurement
test for her. If a bone mass measurement test is ordered for a woman following
a careful evaluation of her medical need, it is expected that the
ordering/treating physician/qualified non-physician practitioner will
document, why he or she believes that the woman is estrogen deficient and at
clinical risk for osteoporosis.

A 2018 systematic review for the U.S. Preventive Services Task Force (USPSTF)
evaluated the evidence on screening for osteoporosis. The review considered
centrally measured DXA to be the reference standard against which other
screening measures were evaluated. Randomized controlled trials (RCTs)
included in the systematic review have shown that osteoporosis medications are
effective at reducing fracture risk in postmenopausal women with bone mineral
density (BMD) in the osteoporotic range identified by central DXA. A noted
limitation of the review was that treatment studies relied on DXA BMD scores
to enroll participants into trials and that risk factors beyond bone density,
such as bone quality, contribute to osteoporotic fractures. Therefore,
"approaches that rely on BMD measurement wholly or in part may not be the most
accurate approaches for identifying patients at highest risk for osteoporotic
fractures."

For individuals who are eligible for screening of BMD based on risk factor
assessment who receive DXA analysis of central sites (hip or spine), the
evidence includes systematic reviews of RCTs and cohort studies. Relevant
outcomes are morbid events, functional outcomes, quality of life (QOL),
hospitalizations, and medication use. Central DXA is the most widely accepted
method for measuring BMD and is the reference standard against which other
screening tests are evaluated. BMD measurements with central DXA identify
individuals at increased risk of fracture, and osteoporosis medications reduce
fracture risk in the population identified as osteoporotic by central DXA.
Therefore, test results with initial central DXA can be used to guide therapy.
The evidence is sufficient to determine that the technology results in an
improvement in the net health outcome.

For individuals without osteoporosis on initial screen who receive repeat DXA
analysis of central sites (hip or spine), the evidence includes systematic
reviews of large cohort and observational studies. Relevant outcomes are
morbid events, functional outcomes, QOL, hospitalizations, and medication use.
Little research has been done on the frequency of BMD monitoring for
osteoporosis. The available research has evaluated repeat measurement with
central DXA. Evidence on whether repeat measurements add to risk prediction
compared with a single measurement is mixed. Although the optimal interval may
differ depending on risk factors, current evidence does not support repeat
monitoring in patients with BMD on DXA in the normal range. The evidence is
insufficient to determine that the technology results in an improvement in the
net health outcome. Although the evidence is limited, multiple clinical
practice guidelines recommend repeat DXA in 3-5 years in patients at low-risk
using risk factor assessment. Similarly, multiple guidelines recommend a
repeat screening interval of 1-2 years for high-risk individuals and in
individuals with a baseline evaluation near a fracture intervention threshold
(osteopenia).

For individuals who are receiving pharmacologic treatment for osteoporosis who
receive repeat DXA analysis of central sites (hip or spine), the evidence
includes systematic reviews of RCTs and observational studies. Relevant
outcomes are morbid events, functional outcomes, QOL, hospitalizations, and
medication use. There is no high-quality evidence to guide how often to
monitor BMD during osteoporosis treatment. Within-person variation in
measurement may exceed treatment effects, and fracture risk has been shown to
be reduced in some treatment studies in the absence of changes in BMD.
Together, these results suggest that frequent (i.e., every 2 years) repeat
monitoring has low value. It is unclear whether DXA at the end of the initial
5 years of therapy is sufficiently accurate to guide subsequent therapy. The
evidence is insufficient to determine that the technology results in an
improvement in the net health outcome. Although the evidence is limited,
multiple clinical practice guidelines recommend repeat DXA at intervals of 1-3
years to monitor treatment response in patients who are receiving
pharmacological treatment for osteoporosis, or after a change in, or cessation
of treatment.

For individuals who are eligible for screening of BMD based on risk factor
assessment who receive ultrasound densitometry, or quantitative computed
tomography, or DXA analysis of peripheral sites, the evidence includes
observational studies and systematic reviews. Relevant outcomes are morbid
events, functional outcomes, QOL, hospitalizations, and medication use. In
comparison with central DXA, other measures of bone health showed area under
the curves around 0.80 for the identification of osteoporosis. These
technologies are not commonly used for BMD measurements in practice, and no
studies have shown that they can select patients who benefit from treatment
for osteoporosis. There is little to no evidence on the usefulness of repeat
measurement of BMD using these techniques. The evidence is insufficient to
determine that the technology results in an improvement in the net health
outcome.

Coverage of Bone Mass Measurement is largely outlined in the Medicare Benefits
Policy Manual IOM Pub 100-02 Chapter 15, Section 80.5. The information in this
LCD further outlines coverage for these services utilizing the latest evidence
and guidelines available.