Latest Review Date: October 2024

Category:  Radiology                                                 

POLICY:

Effective for dates of service December 16, 2024 and after:

Screening for vertebral fractures using dual x-ray absorptiometry (DEXA or DXA) or biomechanical computed tomography or morphometric absorptiometry (MXA) is considered investigational.

 

Effective for dates of service prior to December 16, 2024:

Screening for vertebral fractures using dual x-ray absorptiometry (DEXA or DXA) or morphometric absorptiometry (MXA) is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Vertebral fracture assessment (VFA) with densitometry is a technique to assess vertebral fractures at the same time as bone mineral density, using additional software with dual-energy x-ray absorptiometry. The addition of VFA to bone mineral density may augment diagnostic information on fracture risk.

Diagnosis

Only 20-30% of vertebral fractures are recognized clinically and the rest are discovered incidentally on lateral spine radiographs or other imaging studies. Lateral spine radiographs have not been recommended as a component of risk assessment for osteoporosis, because of the cost, radiation exposure and the fact that the x-ray would require a separate procedure in addition to the bone mineral density study using dual x-ray absorptiometry (DXA). However, several densitometers with specialized software are able to perform vertebral fractures assessment (VFA) in conjunction with DXA. The lateral spine scan is performed by using a rotating arm; depending on the densitometer used, the patient can either stay in the supine position after the bone density study or is required to move onto the left decubitus position.

VFA differs from radiologic detection of fractures, as VFA uses a lower radiation exposure and can detect only fractures, while traditional radiograph images can detect other bone and soft tissue abnormalities in addition to spinal fractures. Manufacturers have also referred to this procedure as instant vertebral assessment (IVA), radiographic vertebral assessment (RVA), dual energy vertebral assessment (DVA), or lateral vertebral assessment (LVA).

For both lateral spine radiographs and images with densitometry, vertebral fractures are assessed visually. While a number of grading systems have been proposed, the semiquantitative system of Genant is commonly used. This system grades the deformities from I to III, with Grade I (mild) representing a 20-24% reduction in vertebral height, Grade II (moderate) representing a 25% to 39% reduction in height, and Grade III (severe) representing a 40% or greater reduction in height. The location of the deformity within the vertebrae may also be noted. For example, if only the mid-height of the vertebrae is affected, the wedge deformity is defined as an endplate deformity, if both the anterior and mid heights are deformed, it is a wedge deformity and if the entire vertebrae is deformed it is classed as a crush deformity. A vertebral deformity of at least 20% loss in height is typically considered a fracture. Accurate interpretation of both lateral spine x-rays and VFA imaging is dependent on radiologic training. Thus, device location and availability of appropriately trained personnel may influence diagnostic accuracy.

Biomechanical computed tomography (BCT) is another method of performing VFA which also minimizes radiation exposure. Previously obtained CT scans can be used for BCT analysis in many cases. Exceptions include spinal images performed with contrast and images in which metal is present in the transverse plane of the bone of interest. Analysis is performed in a centralized laboratory, to which clinicians must send CT scans. The BCT calculation involves a non-linear finite element analysis to simulate a fracture event, with outputs including T-score and Z-score of the femoral neck and hip, femoral strength, vertebral strength, vertebral trabecular volume, and vertebral Z-score. Patients are classified as high risk if fragile bone strength (defined as ≤3000 to 6500 Newtons depending on patient sex and location [hip or spine]) or osteoporosis at the hip or spine is found. The classification of increased risk is assigned if low bone strength or low bone mass is identified at the hip or spine.

For additional information regarding bone mineral density (BMD) as a screening for osteoporosis see medical policy #191- Bone Mineral Density Testing.

KEY POINTS:

The most recent literature review was updated through August 21, 2024.

Summary of Evidence

For individuals who are at risk of having vertebral fractures but are not known to have them who receive vertebral fracture assessment (VFA) with densitometry by dual-energy x-ray absorptiometry (DXA), the evidence includes diagnostic accuracy studies and subgroup reanalyses of treatment studies. Relevant outcomes are test accuracy, test validity, and morbid events. There is a lack of direct evidence from screening trials that use densitometry with VFA improves health outcomes. Because direct evidence was not available, a chain of evidence was sought. Evidence was examined on the diagnostic accuracy of VFA in nonosteoporotic patients (i.e., those not already eligible for treatment), the ability of VFA to identify patients for treatment who would not otherwise be identified, and the effectiveness of treatment in this population. Diagnostic accuracy studies have reported variable findings; recent studies have suggested higher diagnostic accuracy of VFA overall compared with standard radiographs than older studies. Studies have found that VFA can identify patients without osteoporosis who may be appropriate candidates for treatment according to recommendations from the Bone Health and Osteoporosis Foundation. However, there is limited evidence on the effectiveness of treatment in this population. No treatment data have been published in patients whose vertebral fracture had been identified using VFA software with densitometry. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are at risk of having vertebral fractures but are not known to have them who receive VFA with biomechanical computed tomography (BCT), the evidence includes retrospective studies. Relevant outcomes are test accuracy, test validity, and morbid events. The available studies have demonstrated that BCT has similar efficacy to DXA in detecting osteoporosis. There is a lack of direct evidence from clinical trials that the use of BCT for VFA improves health outcomes. No treatment data have been published on patients whose vertebral fractures were identified using BCT. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Association of Clinical Endocrinologists and the American College of Endocrinology

The joint guidelines from the American Association of Clinical Endocrinologists and American College of Endocrinology (2016) on the diagnosis and treatment of postmenopausal osteoporosis included VFA recommendations similar to those of the International Society for Clinical Densitometry (below) but did not discuss BCT. An update to the guidelines in 2020 includes stratification of women with osteoporosis into high-risk and very-high-risk features to drive choice and duration of initial therapy. The guidelines also introduce romosozumab into the treatment algorithm and elucidate treatment transitions from agents such as denosumab.

American College of Physicians

The American College of Physicians' guidelines (2017) on the treatment of low bone density or osteoporosis include the following recommendations (Table 1).

Table 1. Guidelines on the Treatment of Low Bone Density or Osteoporosis

Recommendation	GOE	QOE
"ACP recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinically recognized osteoporosis."	Weak	Low
"ACP recommends that clinicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications."	Weak	Low

ACP: American College of Physicians; GOE: grade of evidence; QOE: quality of evidence.

American College of Radiology

The American College of Radiology (ACR) published updated appropriateness criteria for osteoporosis and bone mineral density (BMD) in 2022. DXA VFA is not mentioned among imaging studies in patients undergoing osteoporosis screening or initial imaging of clinically suspected low BMD. For follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low BMD, DXA VFA is usually not appropriate by ACR criteria. Conversely, for follow-up imaging of patients with T-scores less than -1.0 by DXA, DXA VFA is usually appropriate by ACR criteria in patients who meet 1 or more of the following criteria:

• Females ≥70 years of age or males ≥80 years of age;
• Historical height loss >4 cm (>1.5 inches);
• Self-reported but undocumented prior vertebral fracture;
• Glucocorticoid therapy equivalent to ≥5 mg prednisone equivalent per day for ≥3 months.

The 2022 ACR appropriateness criteria do not address BCT.

Bone Health and Osteoporosis Foundation

The Bone Health and Osteoporosis Foundation, formerly the National Osteoporosis Foundation, published an updated clinician's guide to the prevention and treatment of osteoporosis in 2022.  Per the guide, "a vertebral fracture in an adult ≥ 50 years is diagnostic of osteoporosis, even in the absence of a bone density diagnosis. Unfortunately, most vertebral fractures are subclinical or completely asymptomatic. As a result, they may go undiagnosed for many years. At the same time, a high proportion of women with asymptomatic vertebral fractures have BMD levels that would not warrant treatment based on BMD alone. The finding of a previously unrecognized vertebral fracture may change a patient's diagnostic classification, alter fracture risk calculations, and determine treatment decisions. Proactive investigation is required to detect these fractures so that further bone damage can be prevented."

Traditionally, conventional lateral thoracic/lumbar spine X-ray has been considered the gold standard for identification of vertebral fractures; however, the guide notes that "DXA-assisted VFA is emerging as an alternative to radiograph for its convenience, low cost, and minimal radiation exposure." The guide recommends that in order to "to detect subclinical vertebral fractures," clinicians should perform vertebral fracture imaging (X-ray or DXA VFA) in the following:

• Women aged ≥ 65 years if T-score is ≤ -1.0 at the femoral neck;
• Women ≥ 70 years and men ≥ 80 years if T-score is ≤ -1.0 at the lumbar spine, total hip, or femoral neck;
• Men aged 70 to 79 years if T-score is ≤ -1.5 at the lumbar spine, total hip, or femoral neck;
• Postmenopausal women and men ≥50 years with the following specific risk factors:
  • Fracture(s) during adulthood (any cause).
  • Historical height loss of ≥ 1.5 inches (defined as the difference between the current height and peak height).
  • Prospective height loss of ≥ 0.8 inches (defined as the difference between the current height and last documented height measurement).
  • Recent or ongoing long-term glucocorticoid treatment.
  • Diagnosis of hyperparathyroidism.

Biomechanical computed tomography is mentioned in the guideline as a fracture risk assessment technology that is used in research settings and occasionally in clinical practice, but no recommendations regarding BCT are made.

International Society for Clinical Densitometry

In 2023, the International Society for Clinical Densitometry updated its recommendations for selecting patients for vertebral fracture assessment (VFA), these recommendations remain the same as in a 2015 update. Lateral spine imaging with either standard radiography or densitometric VFA is indicated for patients with a T score of less than -1.0 when at least 1 of the following factors are present:

• “Women age ≥70 years or men ≥80 years
• Historical height loss >4 cm (>1.5 inches)
• Self-reported but undocumented prior vertebral fracture
• Glucocorticoid therapy equivalent to ≥5 mg of prednisone per day for ≥3 mo.”

The International Society for Clinical Densitometry 2023 recommendations do not address BCT.

Endocrine Society

The Endocrine Society Clinical Practice Guideline (2019)on pharmacological management of osteoporosis in postmenopausal women states four management principles:

1. “The risk of future fractures in postmenopausal women should be determined using country-specific assessment tools to guide decision-making.
2. Patient preferences should be incorporated into treatment planning.
3. Nutritional and lifestyle interventions and fall prevention should accompany all pharmacologic regimens to reduce fracture risk.
4. Multiple pharmacologic therapies are capable of reducing fracture rates in postmenopausal women at risk with acceptable with acceptable risk-benefit and safety profiles.”

North American Menopause Society

The North American Menopause Society updated its position statement on the management of osteoporosis in postmenopausal women in 2021. The Society states that in order to identify asymptomatic compression vertebral fractures, "evaluation by a lateral thoracolumbar radiograph or VFA by DXA" may be utilized. Per the position statement, BCT has a small advantage over DXA but its role in routine clinical practice is undefined.

U.S. Preventive Services Task Force Recommendations (USPSTF)

The U.S. Preventive Services Task Force (2018) updated its recommendations on screening for osteoporosis to prevent fractures. The recommendations included: “Most treatment guidelines recommend using BMD, as measured by central DXA, to define osteoporosis and the treatment threshold to prevent osteoporotic fractures.” Peripheral DXA and quantitative ultrasound are also described as common bone measurement screening tests for osteoporosis. VFA was not specifically mentioned.

KEY WORDS:

Dual x-ray absorptiometry, DEXA, vertebral fracture, osteoporosis, morphometric x-ray absorptiometry, MXA, Instant vertebral assessment, IVA, Lateral Vertebral Assessment, LVA, bone mineral density, BMD, vertebral fracture assessment (VFA), dual energy vertebral assessment (DVA), Aria, GEHC DXA, TBS iNsight, QCT PRO, Lunar DXA, CT analysis of vertebral fracture, AI radiology assessment, trabecular bone scoring, TBS

APPROVED BY GOVERNING BODIES:

Additional software is needed to perform VFA with a densitometer or BCT, and it must be cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process. Products cleared for marketing by the FDA are shown in the table below. Food and Drug Administration product code KGI.

Table 2. Devices cleared by the U.S. Food and Drug Administration

Device	Manufacturer	Date cleared	510(k) No.	indication
GEHC DXA Bone Densitometers with enCORE version 18	GE Medical Systems Ultrasound & Primary Care Diagnostics LLC	9/19/2019	K191112	For use in vertebral fracture assessment
Aria	GE Medical Systems Ultrasound & Primary Care Diagnostics LLC	4/20/2018	K180782	For use in vertebral fracture assessment
GE Lunar DXA Bone Densitometers with enCORE version 17	GE MEDICAL SYSTEMS ULTRASOUND & PRIMARY CARE DIAGNOSTICS LLC	12/2/2016	K161682	For use in vertebral fracture assessment
TBS iNsight	MEDIMAPS GROUP SA	4/29/2016	K152299	For use in vertebral fracture assessment
QCT PRO ASYNCHRONOUS CALIBRATION MODULE CLINIQCT	MINDWAYS SOFTWARE INC.	8/29/2014	K140342	For use in vertebral fracture assessment
ENCORE VERSION 16 SOFTWARE FOR GE LUNAR DXA BONE DENSITOMETERS	GE MEDICAL SYSTEMS ULTRASOUND & PRIMARY CARE DIAGN	5/15/2014	K133664	For use in vertebral fracture assessment
Biochemanical Computed Tomography
VirtuOst	O.N. Diagnostics	5/19/23	K220402	To assess bone mineral density and strength

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan. 

CURRENT CODING:

CPT codes:

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)
77089	Trabecular bone score structural condition of the bone microarchitecture; using DXA or other imaging, calculation, with interpretation and report on fracture-risk
77090	Trabecular bone score; technical preparation and transmission of data for analysis to be performed elsewhere
77091	Trabecular bone score; technical calculation only
77092	Trabecular bone score; interpretation and report on fracture-risk only by other qualified health care professional
0691T	Automated analysis of an existing computed tomography study for vertebral fracture(s), including assessment of bone density when performed, data preparation, interpretation, and report
0743T	Bone strength and fracture risk using finite element analysis of functional data and bone mineral density (BMD), with concurrent vertebral fracture assessment, utilizing data from a computed tomography scan, retrieval and transmission of the scan data, measurement of bone strength and BMD and classification of any vertebral fractures, with overall fracture-risk assessment, interpretation and report

REFERENCES:

1. Adams AL, Fischer H, Kopperdahl DL, et al. Osteoporosis and hip fracture risk from routine computed tomography scans: The fracture, osteoporosis, and CT utilization study (FOCUS). J Bone Miner Res. Jul 2018; 33(7): 1291-1301.
2. Alsoof D, Anderson G, McDonald CL, et al. Diagnosis and management of vertebral compression fracture. Am J Med. Jul 2022; 135(7): 815-821. 
3. American College of Radiology. ACR appropriateness criteria, osteoporosis and bone mineral density. 2022; acsearch.acr.org/docs/69358/Narrative/. 
4. Bhoopalam N, Campbell SC, Moritz T, et al. Intravenous zoledronic acid to prevent osteoporosis in a veteran population with multiple risk factors for bone loss on androgen deprivation therapy. J Urol. 2009; 182(5):2257-2264.
5. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis-2020 update- 2016. Endocr Pract. Sep 02 2016; 22(Suppl 4):1-42.
6. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis-2020 update. Endocr Pract. May 2020; 26(Suppl 1): 1-46.
7. Curry SJ, Krist AH, Owens DK, et al. Screening for osteoporosis to prevent fractures: us preventive services task force recommendation statement. JAMA. Jun 26 2018; 319(24): 2521-2531.
8. Domiciano DS, Figueiredo CP, Lopes JB, et al. Vertebral fracture assessment by dual X-ray absorptiometry: a valid tool to detect vertebral fractures in community-dwelling older adults in a population-based survey. Arthritis Care Res (Hoboken). 2013; 65(5):809-815.
9. Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. May 2019;104(5):1595-1622.
10. El Maghraoui A, Mounach A, Rezqi A, et al. Vertebral fracture assessment in asymptomatic men and its impact on management. Bone. Apr 2012; 50(4): 853-7.
11. El Maghraoui A, Rezqi A, Mounach A, et al. Systematic vertebral fracture assessment in asymptomatic postmenopausal women. Bone. Jan 2013; 52(1): 176-80.
12. Ferrar L, Jiang G, Clowes J, et al. Comparison of densitometric and radiographic vertebral fracture assessment using the algorithm-based qualitative (ABQ) method in postmenopausal women at low and high risk of fracture. J Bone Miner Res. 2007; 23(1):103-111.
13. Fidler JL, Murthy NS, Khosla S, et al. Comprehensive assessment of osteoporosis and bone fragility with ct colonography. Radiology. Jan 2016; 278(1): 172-80.
14. Gill SM, Hassan A. Routine use of lateral vertebral assessment with DXA scan for detection of silent but debilitating vertebral fractures. Clin Nucl Med. Feb 01 2023; 48(2): 107-111. 
15. Greenspan SL, Nelson JB, Trump DL, et al. Effect of once-weekly oral alendronate on bone loss in men receiving androgen deprivation therapy for prostate cancer. Ann Intern Med. 2007; 146(6):416-424.
16. International Society for Clinical Densitometry. 2019 ISCD Official Positions – Adult. 2019; www.iscd.org/official-positions/2019-iscd-official-positions-adult/.
17. IOM (Institute of Medicine). 2011. Clinical practice guidelines we can trust. Washington, DC: The National Academies Press.
18. Izzy M, Addissie BD, Arab JP, et al. Triple-Phase Computed Tomography May Replace Dual-Energy X-ray Absorptiometry Scan for Evaluation of Osteoporosis in Liver Transplant Candidates. Liver Transpl. Feb 2021; 27(3): 341-348.
19. Jager PL, Jonkman S, Koolhaas W, et al. Combined vertebral fracture assessment and bone mineral density measurement: a new standard in the diagnosis of osteoporosis in academic populations. Osteoporos Int. 2011; 22(4):1059-1068.
20. Kanis JA, Barton IP and Johnell O. Risedronate decreases fracture risk in patients selected solely on the basis of prior vertebral fracture. Osteoporos Int 2005; 16(5): 475-482.
21. Kanterewicz E, Puigoriol E, Garcia-Barrionuevo J, et al. Prevalence of vertebral fractures and minor vertebral deformities evaluated by DXA-assisted vertebral fracture assessment (VFA) in a population-based study of postmenopausal women: the FRODOS study. Osteoporos Int. May 2014; 25(5):1455-1464.
22. Keaveny TM, Clarke BL, Cosman F, et al. Biomechanical computed tomography analysis (bct) for clinical assessment of osteoporosis. Osteoporos Int. Jun 2020; 31(6): 1025-1048.
23. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. Apr 28 2022.
24. Lee JH, Lee YK, Oh SH, et al. A systematic review of diagnostic accuracy of vertebral fracture assessment (VFA) in postmenopausal women and elderly men. Osteoporos Int. May 2016; 27(5):1691-1699.
25. Malgo F, Hamdy NAT, Ticheler CHJM, et al. Value and potential limitations of vertebral fracture assessment (VFA) compared to conventional spine radiography: experience from a fracture liaison service (FLS) and a meta-analysis. Osteoporos Int. Oct 2017;28(10): 2955-2965.
26. Management of Osteoporosis in Postmenopausal Women: The 2021 position statement of The North American Menopause Society. Menopause. Sep 01 2021; 28(9): 973-997.
27. McClung MR, Pinkerton JV, Blake J, et al. Management of osteoporosis in postmenopausal women: The 2021 position statement of The North American Menopause Society. Menopause. Sep 01 2021; 28(9): 973-997.
28. Mrgan M, Mohammed A, Gram J. Combined vertebral assessment and bone densitometry increases the prevalence and severity of osteoporosis in patients referred to DXA scanning. J Clin Densitom. 2013; 16(4):549-553.
29. Qaseem A, Forciea MA, McLean RM, et al. Treatment of low bone density or osteoporosis to prevent fractures in men and women: A clinical practice guideline update from the American College of Physicians. Ann Intern Med. Jun 06 2017; 166(11):818-839.
30. Quandt SA, Thompson DE, Schneider DL, et al. Effect of alendronate on vertebral fracture risk in women with bone mineral density T scores of-1.6 to -2.5 at the femoral neck: The Fracture Intervention Trial. Mayo Clin Proc. Mar 2005;80(3): 343-9.
31. Shepherd JA, Schousboe JT, Broy SB, et al. Executive summary of the 2015 ISCD position development conference on advanced measures from DXA and QCT: Fracture prediction beyond BMD. J Clin Densitom. Jul-Sep 2015; 18(3): 274-86.
32. U.S. Preventive Services Task Force (USPSTF). Draft research plan. Osteoporosis to prevent fractures: Screening. August 12, 2021; www.uspreventiveservicestaskforce.org/uspstf/document/draft-research-plan/osteoporosis-screening-prevent-fractures.
33. Weber NK, Fidler JL, Keaveny TM, et al. Validation of a CT-derived method for osteoporosis screening in IBD patients undergoing contrast-enhanced CT enterography. Am J Gastroenterol. Mar 2014; 109(3): 401-8.
34. Yang J, Mao Y, Nieves JW. Identification of prevalent vertebral fractures using vertebral fracture assessment (VFA) in asymptomatic postmenopausal women: A systematic review and meta-analysis. Bone. Jul 2020; 136: 115358.

POLICY HISTORY:

Medical Policy Group, August 2004 (1)

Medical Policy Administration Committee, August 2004

Available for comment August 24-October 7, 2004

Medical Policy Group, August 2005 (1)

Medical Policy Group, August 2006 (1)

Medical Policy Group, August 2007 (1)

Medical Policy Administration Committee, August 2007

Available for comment July 27-September 10, 2007

Medical Policy Group, February 2009 (1)

Medical Policy Group, August 2010 (1): Key Points updated, no change in policy statement

Medical Policy Group, January 2012 (1): Update to Key Points and Governing Bodies related to MPP update; no change in policy statement

Medical Policy Panel, January 2013

Medical Policy Group, February 2013 (1): Update to Title, Description, Key Points, Key Words, and References; no change to policy statement

Medical Policy Panel, January 2014

Medical Policy Group, January 2014 (1): Update to Key Points and References; no change to policy statement

Medical Policy Panel, May 2014

Medical Policy Group, June 2014 (1): Update to Key Points and References; no change to policy statement.

Medical Policy Group, November 2014: 2015 Annual Coding update. Added codes 77085, 77086 to current coding.  Added Previous coding section to include code 77082.

Medical Policy Panel, May 2015

Medical Policy Group, May 2015 (4): Update made to Key Points.  No change in policy statement.

Medical Policy Panel, September 2016

Medical Policy Group, September 2016 (7):  Update to Key Points and References.  No change in policy statement.

Medical Policy Panel, September 2017

Medical Policy Group, September 2017 (7): Update to Description, Key Points and Practice Guidelines, and References. Removed Previous Coding Section (77082 deleted effective Jan 2015). No change in policy statement.

Medical Policy Panel, October 2018

Medical Policy Group, October 2018 (7):  Update to Key Points and References.  No change in policy statement.

Medical Policy Panel, October 2019

Medical Policy Group, October 2019 (7):  Update to Key Points and References.  No change in policy statement.

Medical Policy Panel, September 2020

Medical Policy Group, October 2020 (7):  Update to Key Points, Approved by Governing Bodies and References. Added Keywords: “Aria, GEHC DXA, TBS iNsight, QCT PRO, Lunar DXA”. No change in policy statement.

Medical Policy Panel, September 2021

Medical Policy Group, September 2021 (7): Updates to Key Points and References. Policy statement updated to remove “not medically necessary,” no change to policy intent.

Medical Policy Group, December 2021 (7): 2022 Annual Coding Update. Added CPT 0691T to the Current coding section. Keywords added: “CT analysis of vertebral fracture, AI radiology assessment.”

Medical Policy Group, July 2022 (7): Added new CPT codes 77089, 77090, 77091, 77092 to the Current coding section. Added Key Words, “trabecular bone scoring, TBS.”

Medical Policy Panel, September 2022

Medical Policy Group, September 2022 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, September 2023

Medical Policy Group, September 2023 (7): Updates to Description, Key Points, Benefit Application, and References. No change to Policy Statement.

Medical Policy Panel, October 2024

Medical Policy Group, October 2024 (7): Updates to Description, Key Points, Approved by Governing Bodies, and References. Title changed to “Vertebral Fracture Assessment with Dual X-Ray Absorptiometry (DEXA) or Biomechanical Computed Tomography.”  Current Coding section updated- added CPT code 0743T. Policy statement updated- added biomechanical computed tomography to investigational statement and removed “morphometric absorptiometry (MXA)” as this application uses DXA. Posted for draft, November 1, 2024 through December 16, 2024.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

 

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

 

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.