Oxford will cover a bone mass measurement test when it meets all of the following criteria:
- It is performed with one of the covered tests listed below.
- dual energy x-ray absorptiometry (DXA)
- radiographic absorptiometry (RA)
- bone sonometry (ultrasound)
- single energy x-ray absorptiometry (SEXA)
- quantitative computed tomography (QCT)
- 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 one of the five categories listed below:
- A woman who has been determined by the physician or a qualified nonphysician 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 three (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.
- 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).
- 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.
- 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.
- Oxford 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).
- For conditions specified, Oxford will cover a bone mass measurement for a qualified individual more frequently than every two years, if medically necessary for the diagnosis or treatment of the individual and if related to the condition listed. In these instances reimbursement may be made for tests performed after eleven months have elapsed since the previous bone mass measurement test. Examples include, but are not limited to, the following medical circumstance:
- Monitoring beneficiaries on long-term glucocorticoid (≥ 5 mg/day) therapy of more than 3 months (patients must be on glucocorticoids for greater than three months duration, but BMM monitoring is at yearly intervals).
- Confirming baseline BMMs to permit monitoring of beneficiaries in the future.
- In addition, bone mass measurement for the following may be reimbursed more frequently than every two 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.
- 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).
- 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).
- The test must include a physician’s interpretation of the results.
- 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.
