Bone (Mineral) Density Studies - 5/16 · Bone (Mineral) Density Studies ... A bone mineral density (BMD) ... G40.501 Epileptic seizures related to external causes,

Bone (Mineral) Density Studies

Policy Number: Original Effective Date: MM.05.002 03/23/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 05/01/2016 Section: Radiology Place(s) of Service: Outpatient

I. Description

A bone mineral density (BMD) study is a non-invasive technique that is used to measure bone mineral content and bone mineral density. Its primary role is to detect osteoporosis and to predict the risk of fractures. Osteoporosis is a disease that results in the loss of bone mineral content or bone density. This leads to thinning and weakening of bones, increasing the risk of fractures.

BMD can be measured with a variety of techniques in a variety of sites that are subdivided into central (hip or spine) and peripheral (wrist, finger or heel). Dual x-ray absorptiometry (DXA) is the most commonly used technique for BMD measurements. Ultrasound (US) densitometry is as an office based technology for measuring BMD at peripheral sites, mainly the heel. Peripheral measurements can identify patients with low bone mass, but cannot predict response to pharmacologic therapy and is not a substitute for central BMD measurements. Therefore, central BMD measurements are recommended for the initial diagnosis and for repeat BMD measurements.

This policy does not apply to CPT 77078: Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine). Criteria and guidelines can be found on the National Imaging Associates website at http://www.radmd.com/

II. Criteria/Guidelines

A. An initial BMD study of the hip and/or spine is covered (subject to Limitations and Administrative Guidelines) to assess fracture risk and the need for pharmacologic therapy in the following individuals considered to be at high-risk for osteoporosis:

1. Women 65 years of age or older and men 70 years of age or older

2. Postmenopausal women with any of the following risk factors: a. History of a low-impact fracture* after age 45 in a first-degree relative b. Body weight of less than 127 lbs. or BMI of 20 or less c. Current smoker d. Surgical or natural menopause before age 40

http://www.radmd.com/

Bone Mineral Density Studies 2

3. Premenopausal women with documented hypo-estrogenic amenorrhea for more than one year

4. Men or women with the following chronic conditions known to be associated with bone loss:

a. Cushing's syndrome b. Male hypogonadism for more than five years c. Hyperthyroidism d. Hyperparathyroidism e. Ankylosing spondylitis f. Rheumatoid arthritis g. Systemic lupus erythematosus h. Leukemia i. Multiple myeloma j. Chronic kidney disease (stages III, IV and V) k. Celiac disease l. Prolonged severe loss of mobility (unable to ambulate outside of one's dwelling without

a wheelchair for more than one year)

5. Patients taking any of the following medications associated with bone loss:

a. Anticonvulsants b. Oral glucocorticoids for more than three months at a dose equivalent to 5 mg of

prednisone or greater per day c. Aromatase inhibitors d. Chemotherapy agents (i.e., methotrexate or other antimetabolites) e. Depo-medroxy progesterone acetate (Depo-Provera) when used for more than two

years f. Gonadotropin-releasing hormone (GnRH) agonists (buserelin, leuprolide, nafarelin)

6. Solid organ or allogeneic bone marrow transplant recipients

7. Patients with osseous abnormalities shown on imaging studies indicative of osteoporosis, osteopenia or a vertebral compression fracture (defined as vertebral body height loss of 20% or more)

8. Adults who have had a documented low-impact fracture (excluding fingers and toes)

9. Children with a disease or condition associated with bone loss or on prolonged medications that are known to decrease bone mass

B. Peripheral BMD studies are covered (subject to Limitations/Exclusions and Administrative Guidelines) if the hip/spine cannot be done or the patient is over the table limit for weight

A low-impact fracture is defined as a fracture occurring spontaneously or from a fall from standing height, including fractures from activities such as a cough, sneeze or abrupt movement (e.g., opening a window)


III. Limitations/Exclusions

A. Routine BMD screening for osteoporosis is not recommended for women under the age of 65 and for men under the age of 70

B. Repeat central BMD studies are limited to one every two years (23 months must past since the previous BMD study) for patients whose last scan showed osteopenia/osteoporosis

C. Repeat central BMD studies for individuals who previously tested normal may be retested no sooner than three years from the last BMD if they continue to meet the criteria listed above

D. Repeat central BMD studies performed more frequently than once every two years are limited to individuals currently taking an aromatase inhibitor or on glucocorticoid therapy equivalent to 5.0 mg or more of prednisone per day for more than three months

E. A follow up DXA is not covered when used to confirm a diagnosis obtained by an US or QCT

F. Clinicians are encouraged to use the same facility and same scanner for initial and follow-up BMD studies whenever possible for greater consistency

G. Dual Photon Absorptiometry (DPA) and images obtained during a BMD study (e.g., rapid vertebral assessment) are not covered

H. 3D reconstruction is not covered for BMD studies IV. Administrative Guidelines

A. Precertification is required for the following:

1. Patients under the age of 18. To precertify, please complete HMSA's Precertification Request and mail or fax the form as indicated. The request must include supporting documentation from the patient's medical records with the high-risk indications that would justify a BMD study as well as the proposed therapy for the patient

2. For follow-up studies performed more frequently than once every two years. Requests must include the previous BMD study results, other pertinent test findings and a list of medications the patient is currently taking

B. Compliance with the provisions in this policy is subject to monitoring, post payment data analysis, and subsequent medical review. The following documentation should be kept in the patient's medical records and made available upon request:

1. Clinical indications to substantiate that the test is reasonable and necessary 2. Physician’s order signed (not rubber-stamped) and dated (mm/dd/yy) 3. The diagnostic evaluation documenting symptoms, other diagnostic X-rays, and physical

exam findings must have been dated at a time reasonably proximate to the scan 4. The name and medication regimen for patients undergoing drug therapy

C. If a patient does not meet HMSA’s guidelines for coverage but has indicated that he or she wants the services performed despite noncoverage, the patient should be asked to sign HMSA's Agreement of Financial Responsibility. A signed waiver indicates that the patient will be responsible for the denied charges

D. When submitting a claim for a BMD study that does not meet HMSA guidelines, append modifier code GA to the CPT code for the service. The use of the GA modifier will alert HMSA

http://www.hmsa.com/portal/provider/FM.Pre-certification_Request_-_General.pdf

http://www.hmsa.com/portal/provider/FM.Pre-certification_Request_-_General.pdf

http://www.hmsa.com/portal/provider/zav_pel.aa.AGR.500.htm


that the claim should be processed to indicate that the patient will be financially responsible for the service, and that the noncovered charges should not be a provider adjustment

E. The signed waiver should be kept in the patient's record. HMSA reserves the right to conduct periodic audits on claims submitted with the GA modifier and review medical records for signed waivers for this service

F. The following codes are provided for informational purposes only. Inclusion/exclusion of a procedure or diagnosis does not constitute or imply coverage or provider reimbursement:

Applicable CPT codes:

CPT Code Description

76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method

77080 Dual energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)

77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Codes that do not meet payment determination criteria:

CPT code Description

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)

78350 Bone density (bone mineral content) study, one or more sites; single photon absorptiometry

78351 Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites

HCPCS Code Description

G0130 Single energy X-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Applicable ICD-10 codes:

ICD-10 Code Description

E21.0 Primary hyperparathyroidism

E21.1 Secondary hyperparathyroidism, not elsewhere classified

E21.2 Other hyperparathyroidism

E21.3 Hyperparathyroidism, unspecified

E24.0 Pituitary-dependent Cushing's disease


E24.2 Drug-induced Cushing's syndrome

E24.3 Ectopic ACTH syndrome

E24.4 Alcohol-induced pseudo-Cushing's syndrome

E24.8 Other Cushing's syndrome

E24.9 Cushing's syndrome, unspecified

E28.310 Symptomatic premature menopause

E28.319 Asymptomatic premature menopause

E28.39 Other primary ovarian failure

E89.40 Asymptomatic postprocedural ovarian failure

E89.41 Symptomatic postprocedural ovarian failure

G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus

G40.009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus

G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus

G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus

G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus

G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus

G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus

G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus

G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus

G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus

G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus

G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic


syndromes with complex partial seizures, intractable, without status epilepticus

G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus

G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus

G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus

G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus

G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus

G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus

G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus

G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus

G40.501 Epileptic seizures related to external causes, not intractable, with status epilepticus

G40.509 Epileptic seizures related to external causes, not intractable, without status epilepticus

G40.801 Other epilepsy, not intractable, with status epilepticus

G40.802 Other epilepsy, not intractable, without status epilepticus

G40.803 Other epilepsy, intractable, with status epilepticus

G40.804 Other epilepsy, intractable, without status epilepticus

G40.811 Lennox-Gastaut syndrome, not intractable, with status epilepticus

G40.812 Lennox-Gastaut syndrome, not intractable, without status epilepticus

G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus

G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus

G40.821 Epileptic spasms, not intractable, with status epilepticus

G40.822 Epileptic spasms, not intractable, without status epilepticus

G40.823 Epileptic spasms, intractable, with status epilepticus

G40.824 Epileptic spasms, intractable, without status epilepticus

G40.89 Other seizures

G40.901 Epilepsy, unspecified, not intractable, with status epilepticus

G40.909 Epilepsy, unspecified, not intractable, without status epilepticus

G40.911 Epilepsy, unspecified, intractable, with status epilepticus

G40.919 Epilepsy, unspecified, intractable, without status epilepticus

G40.A01 Absence epileptic syndrome, not intractable, with status epilepticus

G40.A09 Absence epileptic syndrome, not intractable, without status epilepticus

G40.A11 Absence epileptic syndrome, intractable, with status epilepticus


G40.A19 Absence epileptic syndrome, intractable, without status epilepticus

G40.B01 Juvenile myoclonic epilepsy, not intractable, with status epilepticus

G40.B09 Juvenile myoclonic epilepsy, not intractable, without status epilepticus

G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus

G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus

K90.0 Celiac disease

M05.40 Rheumatoid myopathy with rheumatoid arthritis of unspecified site

M05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulder

M05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulder

M05.419 Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder

M05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbow

M05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbow

M05.429 Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow

M05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist

M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist

M05.439 Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist

M05.441 Rheumatoid myopathy with rheumatoid arthritis of right hand

M05.442 Rheumatoid myopathy with rheumatoid arthritis of left hand

M05.449 Rheumatoid myopathy with rheumatoid arthritis of unspecified hand

M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip

M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip

M05.459 Rheumatoid myopathy with rheumatoid arthritis of unspecified hip

M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee

M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee

M05.469 Rheumatoid myopathy with rheumatoid arthritis of unspecified knee

M05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot

M05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot

M05.479 Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot

M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites

M05.50 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site

M05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder

M05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder

M05.519 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder

M05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow

M05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow

M05.529 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow

M05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist

M05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist

M05.539 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist


M05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand

M05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left hand

M05.549 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand

M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip

M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip

M05.559 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip

M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee

M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee

M05.569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee

M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot

M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot

M05.579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot

M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites

M05.70 Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement

M05.711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement

M05.712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement

M05.719 Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement

M05.721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement

M05.722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement

M05.729 Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement

M05.731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement

M05.732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement

M05.739 Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement

M05.741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement

M05.742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement

M05.749 Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement

M05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement


M05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement

M05.759 Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement

M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement

M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement

M05.769 Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement

M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement

M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement

M05.779 Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement

M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement

M05.80 Other rheumatoid arthritis with rheumatoid factor of unspecified site

M05.811 Other rheumatoid arthritis with rheumatoid factor of right shoulder

M05.812 Other rheumatoid arthritis with rheumatoid factor of left shoulder

M05.819 Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder

M05.821 Other rheumatoid arthritis with rheumatoid factor of right elbow

M05.822 Other rheumatoid arthritis with rheumatoid factor of left elbow

M05.829 Other rheumatoid arthritis with rheumatoid factor of unspecified elbow

M05.831 Other rheumatoid arthritis with rheumatoid factor of right wrist

M05.832 Other rheumatoid arthritis with rheumatoid factor of left wrist

M05.839 Other rheumatoid arthritis with rheumatoid factor of unspecified wrist

M05.841 Other rheumatoid arthritis with rheumatoid factor of right hand

M05.842 Other rheumatoid arthritis with rheumatoid factor of left hand

M05.849 Other rheumatoid arthritis with rheumatoid factor of unspecified hand

M05.851 Other rheumatoid arthritis with rheumatoid factor of right hip

M05.852 Other rheumatoid arthritis with rheumatoid factor of left hip

M05.859 Other rheumatoid arthritis with rheumatoid factor of unspecified hip

M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee

M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee

M05.869 Other rheumatoid arthritis with rheumatoid factor of unspecified knee

M05.871 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot

M05.872 Other rheumatoid arthritis with rheumatoid factor of left ankle and foot

M05.879 Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot

M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites


M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified

M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site

M06.011 Rheumatoid arthritis without rheumatoid factor, right shoulder

M06.012 Rheumatoid arthritis without rheumatoid factor, left shoulder

M06.019 Rheumatoid arthritis without rheumatoid factor, unspecified shoulder

M06.021 Rheumatoid arthritis without rheumatoid factor, right elbow

M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow

M06.029 Rheumatoid arthritis without rheumatoid factor, unspecified elbow

M06.031 Rheumatoid arthritis without rheumatoid factor, right wrist

M06.032 Rheumatoid arthritis without rheumatoid factor, left wrist

M06.039 Rheumatoid arthritis without rheumatoid factor, unspecified wrist

M06.041 Rheumatoid arthritis without rheumatoid factor, right hand

M06.042 Rheumatoid arthritis without rheumatoid factor, left hand

M06.042 Rheumatoid arthritis without rheumatoid factor, left hand

M06.049 Rheumatoid arthritis without rheumatoid factor, unspecified hand

M06.051 Rheumatoid arthritis without rheumatoid factor, right hip

M06.052 Rheumatoid arthritis without rheumatoid factor, left hip

M06.059 Rheumatoid arthritis without rheumatoid factor, unspecified hip

M06.061 Rheumatoid arthritis without rheumatoid factor, right knee

M06.062 Rheumatoid arthritis without rheumatoid factor, left knee

M06.069 Rheumatoid arthritis without rheumatoid factor, unspecified knee

M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and foot

M06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and foot

M06.079 Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot

M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae

M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites

M06.20 Rheumatoid bursitis, unspecified site

M06.211 Rheumatoid bursitis, right shoulder

M06.212 Rheumatoid bursitis, left shoulder

M06.219 Rheumatoid bursitis, unspecified shoulder

M06.221 Rheumatoid bursitis, right elbow

M06.222 Rheumatoid bursitis, left elbow

M06.229 Rheumatoid bursitis, unspecified elbow

M06.231 Rheumatoid bursitis, right wrist

M06.232 Rheumatoid bursitis, left wrist

M06.239 Rheumatoid bursitis, unspecified wrist

M06.241 Rheumatoid bursitis, right hand

M06.242 Rheumatoid bursitis, left hand


M06.249 Rheumatoid bursitis, unspecified hand

M06.251 Rheumatoid bursitis, right hip

M06.252 Rheumatoid bursitis, left hip

M06.259 Rheumatoid bursitis, unspecified hip

M06.261 Rheumatoid bursitis, right knee

M06.262 Rheumatoid bursitis, left knee

M06.269 Rheumatoid bursitis, unspecified knee

M06.271 Rheumatoid bursitis, right ankle and foot

M06.272 Rheumatoid bursitis, left ankle and foot

M06.279 Rheumatoid bursitis, unspecified ankle and foot

M06.28 Rheumatoid bursitis, vertebrae

M06.29 Rheumatoid bursitis, multiple sites

M06.30 Rheumatoid nodule, unspecified site

M06.311 Rheumatoid nodule, right shoulder

M06.312 Rheumatoid nodule, left shoulder

M06.319 Rheumatoid nodule, unspecified shoulder

M06.321 Rheumatoid nodule, right elbow

M06.322 Rheumatoid nodule, left elbow

M06.329 Rheumatoid nodule, unspecified elbow

M06.331 Rheumatoid nodule, right wrist

M06.332 Rheumatoid nodule, left wrist

M06.339 Rheumatoid nodule, unspecified wrist

M06.341 Rheumatoid nodule, right hand

M06.342 Rheumatoid nodule, left hand

M06.349 Rheumatoid nodule, unspecified hand

M06.351 Rheumatoid nodule, right hip

M06.352 Rheumatoid nodule, left hip

M06.359 Rheumatoid nodule, unspecified hip

M06.361 Rheumatoid nodule, right knee

M06.362 Rheumatoid nodule, left knee

M06.369 Rheumatoid nodule, unspecified knee

M06.371 Rheumatoid nodule, right ankle and foot

M06.372 Rheumatoid nodule, left ankle and foot

M06.379 Rheumatoid nodule, unspecified ankle and foot

M06.38 Rheumatoid nodule, vertebrae

M06.39 Rheumatoid nodule, multiple sites

M06.80 Other specified rheumatoid arthritis, unspecified site


M06.811 Other specified rheumatoid arthritis, right shoulder

M06.812 Other specified rheumatoid arthritis, left shoulder

M06.819 Other specified rheumatoid arthritis, unspecified shoulder

M06.821 Other specified rheumatoid arthritis, right elbow

M06.822 Other specified rheumatoid arthritis, left elbow

M06.829 Other specified rheumatoid arthritis, unspecified elbow

M06.831 Other specified rheumatoid arthritis, right wrist

M06.832 Other specified rheumatoid arthritis, left wrist

M06.839 Other specified rheumatoid arthritis, unspecified wrist

M06.841 Other specified rheumatoid arthritis, right hand

M06.842 Other specified rheumatoid arthritis, left hand

M06.849 Other specified rheumatoid arthritis, unspecified hand

M06.851 Other specified rheumatoid arthritis, right hip

M06.852 Other specified rheumatoid arthritis, left hip

M06.859 Other specified rheumatoid arthritis, unspecified hip

M06.861 Other specified rheumatoid arthritis, right knee

M06.862 Other specified rheumatoid arthritis, left knee

M06.869 Other specified rheumatoid arthritis, unspecified knee

M06.871 Other specified rheumatoid arthritis, right ankle and foot

M06.872 Other specified rheumatoid arthritis, left ankle and foot

M06.879 Other specified rheumatoid arthritis, unspecified ankle and foot

M06.88 Other specified rheumatoid arthritis, vertebrae

M06.89 Other specified rheumatoid arthritis, multiple sites

M06.9 Rheumatoid arthritis, unspecified

M08.1 Juvenile ankylosing spondylitis

M32.0 Drug-induced systemic lupus erythematosus

M32.10 Systemic lupus erythematosus, organ or system involvement unspecified

M32.11 Endocarditis in systemic lupus erythematosus

M32.12 Pericarditis in systemic lupus erythematosus

M32.13 Lung involvement in systemic lupus erythematosus

M32.14 Glomerular disease in systemic lupus erythematosus

M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus

M32.19 Other organ or system involvement in systemic lupus erythematosus

M32.8 Other forms of systemic lupus erythematosus

M32.9 Systemic lupus erythematosus, unspecified

M45.0 Ankylosing spondylitis of multiple sites in spine

M45.1 Ankylosing spondylitis of occipito-atlanto-axial region


M45.2 Ankylosing spondylitis of cervical region

M45.3 Ankylosing spondylitis of cervicothoracic region

M45.4 Ankylosing spondylitis of thoracic region

M45.5 Ankylosing spondylitis of thoracolumbar region

M45.6 Ankylosing spondylitis lumbar region

M45.7 Ankylosing spondylitis of lumbosacral region

M45.8 Ankylosing spondylitis sacral and sacrococcygeal region

M45.9 Ankylosing spondylitis of unspecified sites in spine

M48.8x1 Other specified spondylopathies, occipito-atlanto-axial region

M48.8x2 Other specified spondylopathies, cervical region

M48.8x3 Other specified spondylopathies, cervicothoracic region

M48.8x4 Other specified spondylopathies, thoracic region

M48.8x5 Other specified spondylopathies, thoracolumbar region

M48.8x6 Other specified spondylopathies, lumbar region

M48.8x7 Other specified spondylopathies, lumbosacral region

M48.8x8 Other specified spondylopathies, sacral and sacrococcygeal region

M48.8x9 Other specified spondylopathies, site unspecified

M80.00xA Age-related osteoporosis with current pathological fracture, unspecified

site, initial encounter for fracture

M80.00xD Age-related osteoporosis with current pathological fracture, unspecified

site, subsequent encounter for fracture with routine healing

M80.00xG Age-related osteoporosis with current pathological fracture, unspecified

site, subsequent encounter for fracture with delayed healing

M80.00xK Age-related osteoporosis with current pathological fracture, unspecified

site, subsequent encounter for fracture with nonunion

M80.00xP Age-related osteoporosis with current pathological fracture, unspecified

site, subsequent encounter for fracture with malunion

M80.00xS Age-related osteoporosis with current pathological fracture, unspecified

site, sequela

M80.031A Age-related osteoporosis with current pathological fracture, right forearm,

initial encounter for fracture

M80.031D Age-related osteoporosis with current pathological fracture, right forearm,

subsequent encounter for fracture with routine healing

M80.031G Age-related osteoporosis with current pathological fracture, right forearm,

subsequent encounter for fracture with delayed healing

M80.031K Age-related osteoporosis with current pathological fracture, right forearm,

subsequent encounter for fracture with nonunion


M80.031P Age-related osteoporosis with current pathological fracture, right forearm,

subsequent encounter for fracture with malunion

M80.031S Age-related osteoporosis with current pathological fracture, right forearm,

sequela

M80.032A Age-related osteoporosis with current pathological fracture, left forearm,


M80.032D Age-related osteoporosis with current pathological fracture, left forearm,


M80.032G Age-related osteoporosis with current pathological fracture, left forearm,


M80.032K Age-related osteoporosis with current pathological fracture, left forearm,


M80.032P Age-related osteoporosis with current pathological fracture, left forearm,


M80.032S Age-related osteoporosis with current pathological fracture, left forearm,

sequela

M80.039A Age-related osteoporosis with current pathological fracture, unspecified

forearm, initial encounter for fracture

M80.039D Age-related osteoporosis with current pathological fracture, unspecified

forearm, subsequent encounter for fracture with routine healing

M80.039G Age-related osteoporosis with current pathological fracture, unspecified

forearm, subsequent encounter for fracture with delayed healing

M80.039K Age-related osteoporosis with current pathological fracture, unspecified

forearm, subsequent encounter for fracture with nonunion

M80.039P Age-related osteoporosis with current pathological fracture, unspecified

forearm, subsequent encounter for fracture with malunion

M80.039S Age-related osteoporosis with current pathological fracture, unspecified

forearm, sequela

M80.80xA Other osteoporosis with current pathological fracture, unspecified site,


M80.80xD Other osteoporosis with current pathological fracture, unspecified site,


M80.80xG Other osteoporosis with current pathological fracture, unspecified site,


M80.80xK Other osteoporosis with current pathological fracture, unspecified site,


M80.80xP Other osteoporosis with current pathological fracture, unspecified site,



M80.80xS Other osteoporosis with current pathological fracture, unspecified site,

sequela

M80.831A Other osteoporosis with current pathological fracture, right forearm, initial

encounter for fracture

M80.831D Other osteoporosis with current pathological fracture, right forearm,


M80.831G Other osteoporosis with current pathological fracture, right forearm,


M80.831K Other osteoporosis with current pathological fracture, right forearm,


M80.831P Other osteoporosis with current pathological fracture, right forearm,


M80.831S Other osteoporosis with current pathological fracture, right forearm,

sequela

M80.832A Other osteoporosis with current pathological fracture, left forearm, initial


M80.832D Other osteoporosis with current pathological fracture, left forearm,


M80.832G Other osteoporosis with current pathological fracture, left forearm,


M80.832K Other osteoporosis with current pathological fracture, left forearm,


M80.832P Other osteoporosis with current pathological fracture, left forearm,


M80.832S Other osteoporosis with current pathological fracture, left forearm, sequela

M80.839A Other osteoporosis with current pathological fracture, unspecified forearm,


M80.839D Other osteoporosis with current pathological fracture, unspecified forearm,


M80.839G Other osteoporosis with current pathological fracture, unspecified forearm,


M80.839K Other osteoporosis with current pathological fracture, unspecified forearm,


M80.839P Other osteoporosis with current pathological fracture, unspecified forearm,


M80.839S Other osteoporosis with current pathological fracture, unspecified forearm,


sequela

M81.0 Age-related osteoporosis without current pathological fracture

M81.6 Localized osteoporosis [Lequesne]

M81.8 Other osteoporosis without current pathological fracture

M84.40xA Pathological fracture, unspecified site, initial encounter for fracture

M84.40xD Pathological fracture, unspecified site, subsequent encounter for fracture

with routine healing

M84.40xG Pathological fracture, unspecified site, subsequent encounter for fracture

with delayed healing

M84.40xK Pathological fracture, unspecified site, subsequent encounter for fracture

with nonunion

M84.40xP Pathological fracture, unspecified site, subsequent encounter for fracture

with malunion

M84.40xS Pathological fracture, unspecified site, sequela

M84.431A Pathological fracture, right ulna, initial encounter for fracture

M84.431D Pathological fracture, right ulna, subsequent encounter for fracture with

routine healing

M84.431G Pathological fracture, right ulna, subsequent encounter for fracture with

delayed healing

M84.431K Pathological fracture, right ulna, subsequent encounter for fracture with

nonunion

M84.431P Pathological fracture, right ulna, subsequent encounter for fracture with

malunion

M84.431S Pathological fracture, right ulna, sequela

M84.432A Pathological fracture, left ulna, initial encounter for fracture

M84.432D Pathological fracture, left ulna, subsequent encounter for fracture with

routine healing

M84.432G Pathological fracture, left ulna, subsequent encounter for fracture with

delayed healing

M84.432K Pathological fracture, left ulna, subsequent encounter for fracture with

nonunion

M84.432P Pathological fracture, left ulna, subsequent encounter for fracture with

malunion

M84.432S Pathological fracture, left ulna, sequela

M84.433A Pathological fracture, right radius, initial encounter for fracture

M84.433D Pathological fracture, right radius, subsequent encounter for fracture with

routine healing


M84.433G Pathological fracture, right radius, subsequent encounter for fracture with

delayed healing

M84.433K Pathological fracture, right radius, subsequent encounter for fracture with

nonunion

M84.433P Pathological fracture, right radius, subsequent encounter for fracture with

malunion

M84.433S Pathological fracture, right radius, sequela

M84.434A Pathological fracture, left radius, initial encounter for fracture

M84.434D Pathological fracture, left radius, subsequent encounter for fracture with

routine healing

M84.434G Pathological fracture, left radius, subsequent encounter for fracture with

delayed healing

M84.434K Pathological fracture, left radius, subsequent encounter for fracture with

nonunion

M84.434P Pathological fracture, left radius, subsequent encounter for fracture with

malunion

M84.434S Pathological fracture, left radius, sequela

M84.439K Pathological fracture, unspecified ulna and radius, subsequent encounter

for fracture with nonunion

M84.439P Pathological fracture, unspecified ulna and radius, subsequent encounter

for fracture with malunion

M84.439S Pathological fracture, unspecified ulna and radius, sequela

M84.50xA Pathological fracture in neoplastic disease, unspecified site, initial


M84.50xD Pathological fracture in neoplastic disease, unspecified site, subsequent

encounter for fracture with routine healing

M84.50xG Pathological fracture in neoplastic disease, unspecified site, subsequent

encounter for fracture with delayed healing

M84.50xK Pathological fracture in neoplastic disease, unspecified site, subsequent

encounter for fracture with nonunion

M84.50xP Pathological fracture in neoplastic disease, unspecified site, subsequent

encounter for fracture with malunion

M84.50xS Pathological fracture in neoplastic disease, unspecified site, sequela

M84.531A Pathological fracture in neoplastic disease, right ulna, initial encounter for

fracture

M84.531D Pathological fracture in neoplastic disease, right ulna, subsequent



M84.531G Pathological fracture in neoplastic disease, right ulna, subsequent


M84.531K Pathological fracture in neoplastic disease, right ulna, subsequent


M84.531P Pathological fracture in neoplastic disease, right ulna, subsequent


M84.531S Pathological fracture in neoplastic disease, right ulna, sequela

M84.532A Pathological fracture in neoplastic disease, left ulna, initial encounter for

fracture

M84.532D Pathological fracture in neoplastic disease, left ulna, subsequent encounter

for fracture with routine healing

M84.532G Pathological fracture in neoplastic disease, left ulna, subsequent encounter

for fracture with delayed healing

M84.532K Pathological fracture in neoplastic disease, left ulna, subsequent encounter


M84.532P Pathological fracture in neoplastic disease, left ulna, subsequent encounter


M84.532S Pathological fracture in neoplastic disease, left ulna, sequela

M84.533A Pathological fracture in neoplastic disease, right radius, initial encounter for

fracture

M84.533D Pathological fracture in neoplastic disease, right radius, subsequent


M84.533G Pathological fracture in neoplastic disease, right radius, subsequent


M84.533K Pathological fracture in neoplastic disease, right radius, subsequent


M84.533P Pathological fracture in neoplastic disease, right radius, subsequent


M84.533S Pathological fracture in neoplastic disease, right radius, sequela

M84.534A Pathological fracture in neoplastic disease, left radius, initial encounter for

fracture

M84.534D Pathological fracture in neoplastic disease, left radius, subsequent


M84.534G Pathological fracture in neoplastic disease, left radius, subsequent


M84.534K Pathological fracture in neoplastic disease, left radius, subsequent



M84.534P Pathological fracture in neoplastic disease, left radius, subsequent


M84.534S Pathological fracture in neoplastic disease, left radius, sequela

M84.539A Pathological fracture in neoplastic disease, unspecified ulna and radius,


M84.539D Pathological fracture in neoplastic disease, unspecified ulna and radius,


M84.539G Pathological fracture in neoplastic disease, unspecified ulna and radius,


M84.539K Pathological fracture in neoplastic disease, unspecified ulna and radius,


M84.539P Pathological fracture in neoplastic disease, unspecified ulna and radius,


M84.539S Pathological fracture in neoplastic disease, unspecified ulna and radius,

sequela

M84.60xA Pathological fracture in other disease, unspecified site, initial encounter for

fracture

M84.60xD Pathological fracture in other disease, unspecified site, subsequent


M84.60xG Pathological fracture in other disease, unspecified site, subsequent


M84.60xK Pathological fracture in other disease, unspecified site, subsequent


M84.60xP Pathological fracture in other disease, unspecified site, subsequent


M84.60xS Pathological fracture in other disease, unspecified site, sequela

M84.631A Pathological fracture in other disease, right ulna, initial encounter for

fracture

M84.631D Pathological fracture in other disease, right ulna, subsequent encounter for

fracture with routine healing

M84.631G Pathological fracture in other disease, right ulna, subsequent encounter for

fracture with delayed healing

M84.631K Pathological fracture in other disease, right ulna, subsequent encounter for

fracture with nonunion

M84.631P Pathological fracture in other disease, right ulna, subsequent encounter for

fracture with malunion

M84.631S Pathological fracture in other disease, right ulna, sequela


M84.632A Pathological fracture in other disease, left ulna, initial encounter for

fracture

M84.632D Pathological fracture in other disease, left ulna, subsequent encounter for


M84.632G Pathological fracture in other disease, left ulna, subsequent encounter for


M84.632K Pathological fracture in other disease, left ulna, subsequent encounter for


M84.632P Pathological fracture in other disease, left ulna, subsequent encounter for


M84.632S Pathological fracture in other disease, left ulna, sequela

M84.633A Pathological fracture in other disease, right radius, initial encounter for

fracture

M84.633D Pathological fracture in other disease, right radius, subsequent encounter

for fracture with routine healing

M84.633G Pathological fracture in other disease, right radius, subsequent encounter

for fracture with delayed healing

M84.633K Pathological fracture in other disease, right radius, subsequent encounter


M84.633P Pathological fracture in other disease, right radius, subsequent encounter


M84.633S Pathological fracture in other disease, right radius, sequela

M84.634A Pathological fracture in other disease, left radius, initial encounter for

fracture

M84.634D Pathological fracture in other disease, left radius, subsequent encounter for


M84.634G Pathological fracture in other disease, left radius, subsequent encounter for


M84.634K Pathological fracture in other disease, left radius, subsequent encounter for


M84.634P Pathological fracture in other disease, left radius, subsequent encounter for


M84.634S Pathological fracture in other disease, left radius, sequela

M84.639A Pathological fracture in other disease, unspecified ulna and radius, initial


M84.639D Pathological fracture in other disease, unspecified ulna and radius,



M84.639G Pathological fracture in other disease, unspecified ulna and radius,


M84.639K Pathological fracture in other disease, unspecified ulna and radius,


M84.639P Pathological fracture in other disease, unspecified ulna and radius,


M84.639S Pathological fracture in other disease, unspecified ulna and radius, sequela

M85.80 – M85.89

Other specified disorders of bone density and structure

M85.9 Disorder of bone density and structure, unspecified

M89.9 Disorder of bone, unspecified

M94.9 Disorder of cartilage, unspecified

N18.3 Chronic kidney disease, stage 3 (moderate)

N18.4 Chronic kidney disease, stage 4 (severe)

N18.5 Chronic kidney disease, stage 5

N25.81 Secondary hyperparathyroidism of renal origin

N91.0 Primary amenorrhea

N91.1 Secondary amenorrhea

N91.2 Amenorrhea, unspecified

N91.3 Primary oligomenorrhea

N91.4 Secondary oligomenorrhea

N91.5 Oligomenorrhea, unspecified

N95.1 Menopausal and female climacteric states

N95.2 Postmenopausal atrophic vaginitis

N95.8 Other specified menopausal and perimenopausal disorders

N95.9 Unspecified menopausal and perimenopausal disorder

T38.0x5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter

T38.0x5S Adverse effect of glucocorticoids and synthetic analogues, sequela

T38.4x5A Adverse effect of oral contraceptives, initial encounter

T38.4x5S Adverse effect of oral contraceptives, sequela

T38.5x5A Adverse effect of other estrogens and progestogens, initial encounter

T38.5x5S Adverse effect of other estrogens and progestogens, sequela

T50.0x5A Adverse effect of mineralocorticoids and their antagonists, initial encounter

T50.0x5S Adverse effect of mineralocorticoids and their antagonists, sequela

Z08 Encounter for follow-up examination after completed treatment for

malignant neoplasm

Z09 Encounter for follow-up examination after completed treatment for


conditions other than malignant neoplasm

Z13.820 Encounter for screening for osteoporosis

Z78.0 Asymptomatic menopausal state

Z79.3 Long term (current) use of hormonal contraceptives

Z79.51 Long term (current) use of inhaled steroids

Z79.52 Long term (current) use of systemic steroids

Z79.891 Long term (current) use of opiate analgesic

Z79.899 Other long term (current) drug therapy

V. Important Reminder

The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician.

Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii's Patients' Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA's determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation.

VI. References

1. Watts NB, Bilezikian JP, Camacho PM, Greenspan SL, Harris ST, Hodgson SF, Kleerekoper M, Luckey MM, McClung MR, Pollack RP, Petak SM, AACE Osteoporosis Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis. Endocr Pract. 2010 Nov-Dec; 16(Suppl 3):1-37.

2. BCBSA Medical Policy Reference Manual. Bone density studies. Policy #6.01.01. Last review March 2015

3. Diagnosis of Osteoporosis in Men, Premenopausal Women, and Children. J Clin Densitom 2004 Spring; 7(1):17-26. [82 references]

4. Hau Liu, Neil M. Paige, et.al: Screening for osteoporosis in men: A systematic review from the American College of Physicians Guideline. Ann Intern Med, May 2008; 148: 685-701.


5. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline, Diagnosis and Treatment of Osteoporosis. Eighth Edition July 2013

6. National Osteoporosis Foundation: Clinicians Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2014.

7. U.S. Preventive Services Task Force. Screening for Osteoporosis. Recommendation Statement. January 2011. Agency for Healthcare Research and Quality, Rockville, MD.

8. Ward L, et al; Bisphosphonate Therapy for Children and Adolescents with Secondary Osteoporosis. Premedline identifier 17943849. Cochrane database sys rev. 2007.

9. Conference of Radiation Control Program Directors' Task Force on Bone Densitometry. Technical white paper: Bone Densitometry. October 2006.

10. Adams J et al. Vertebral Fracture Initiative Part II Radiological Assessment of Vertebral Fracture. International Osteoporosis Foundation. 1-49.

11. World Health Organization Collaborating Centre for Metabolic Bone Diseases. WHO Fracture Risk Assessment tool. Available online at http://www.shef.ac.uk/FRAX/tool.jsp

http://www.shef.ac.uk/FRAX/tool.jsp

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