General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided.  If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Purpose
Bone mineral density (BMD) measurement identifies patients with low bone density and increased fracture risk. Methods for measuring BMD are non-invasive, painless, and available on an outpatient basis.

Special Note
See Legislative Requirements for specific mandates in Washington State.

Background
Dual energy X-ray absorptiometry (DXA), previously referred to as DEXA, is the most commonly used method of evaluating BMD and is the only BMD technology for which World Health Organization (WHO) criteria for the diagnosis of osteoporosis can be used. Patients who have a BMD that is 2.5 standard deviations below that of a “young normal” adult (T-score at or below -2.5) are deemed to have osteoporosis. Quantitative computed tomography (QCT) has not been validated for WHO criteria but can identify patients with low BMD compared to the QCT reference database, and it can be used to identify patients who are at risk of fracture.

DXA and QTC
Dual energy X-ray absorptiometry (DXA) is most often used to measure bone mineral density due to its low radiation exposure, low precision error, and capacity to measure multiple skeletal sites (spine, hip, or total body).

Axial DXA provides the “gold standard”. Axial DXA predicts fracture risk at the site being measured.

Peripheral DXA measures BMD at peripheral sites, generally at the heel or wrist. It is relatively cheap and portable and is an option when there is limited access to axial DXA.

Quantitative computed tomography (QCT) measures volumetric integral, trabecular, and cortical bone density at the spine and hip and can be used to determine bone strength. 

Radiation dose is increased when compared with DXA. Indications are the same for QCT as DXA; however, DXA is recommended as the first-line test in most cases.^1,3

Policy 
INDICATIONS FOR CT BONE DENSITY STUDY

For first time baseline study^1,2,3,4,5

Patient with suspected osteoporosis or osteopenia meeting any of the following criteria when DXA scanning is not available or for patients with advanced degenerative changes of the spine or who are severely obese (BMI > 35 kg/m) that may limit the efficacy of DXA scans.

• Asymptomatic women 65 years of age or older
• For post-menopausal women age < 65 or during the menopause transition, and men < 70 having at least one of the following risk factors for low bone mass or fractures:
  • Low body weight (< 127 lb. or 57.6 kg or BMI < 20 kg per m)
  • A history of fracture
  • History of maternal hip fracture that occurred after the age of 50 years
  • High risk medications (e.g., steroids or glucocorticosteroids, medroxyprogesterone acetate, anticonvulsants, heparin, lithium, estrogen receptor modulators, calcitonin, or bisphosphonates)
  • History of estrogen deficiency
  • Conditions that cause or contribute to osteoporosis and fractures (e.g., malabsorption syndromes, inflammatory bowel disease and other gastrointestinal conditions, metabolic bone disease, hyperparathyroidism, hypogonadism, thyroid hormone therapy or hyperthyroidism, chemotherapy, long-term heparin therapy, rheumatologic and autoimmune diseases, renal failure, hematologic disorders, multiple myeloma, chronic alcoholism, cerebral palsy, etc.)
• Men aged 70 or older
• Individuals with fragility fractures, including vertebral abnormalities that are indicative of osteoporosis, osteopenia, low bone mineral content, or vertebral fractures seen on other imaging studies/X-ray
• Individuals aged 50 years and older who develop a wrist, hip, spine, or proximal humerus fracture with minimal or no trauma, excluding pathologic fractures
• Loss of body height (> 4 cm [> 1.5 inches])¹
• Amenorrhea for greater than 1 year before the age of 42
• Eating disorders, including anorexia nervosa and bulimia
• Individuals who have had gastric bypass for obesity (accuracy of DXA may be affected by obesity)

Follow-up of individuals with known osteoporosis or osteopenia^6,7

• In women with low to moderate risk reassess fracture risk in 2 – 4 years
• In post-menopausal women with a low bone mineral density at high risk for fractures on treatment, monitor the spine and hip every 1 – 3 years
• For patients on bisphosphonates, reassess fracture risk every 3 – 5 years
• No previous bone density within past 23 months AND meets any one of the above risk factor criteria. (More frequent BMD testing may be warranted in certain clinical situations and should be determined on a case-by-case basis.)

Indications for QCT/pQCT in pediatric and adolescent include:⁸

• Individuals receiving (or expected to receive) glucocorticoid therapy for more than 3 months.
• Individuals receiving radiation or chemotherapy for malignancies.
• Individuals with an endocrine disorder known to adversely affect BMD (e.g., hyperparathyroidism, hyperthyroidism, growth hormone deficiency or Cushing’s syndrome).
• Individuals with bone dysplasias known to have excessive fracture risk (osteogenesis imperfecta, osteopetrosis) or high BMD, such as prolonged exposure to fluoride.
• Individuals with medical conditions that could alter bone marrow density, such as: (chronic renal failure, inflammatory arthritides, eating disorders, organ transplantation, prolonged immobilization, sprue, inflammatory bowel disease, malnutrition, cystic fibrosis, osteomalacia, acromegaly, cirrhosis, HIV infection, prolonged exposure to fluorides, and hematologic disorders [thalassemia, sickle cell disease]).

References 

1. Yu J S, Krishna N G, Fox M G, Blankenbaker D G, Frick M A et al. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. Journal of the American College of Radiology. 2022; 19: S417 - S432. 10.1016/j.jacr.2022.09.007. 
2. ACR-SPR-SSR. ACR–SPR–SSR PRACTICE PARAMETER FOR THE PERFORMANCE OF QUANTITATIVE COMPUTED TOMOGRAPHY (QCT) BONE MINERAL DENSITY. American College of Radiology. 2023.
3. Cosman F, de Beur S J, LeBoff M S, Lewiecki E M, Tanner B et al. Clinicians Guide to Prevention and Treatment of Osteoporosis. Osteoporosis international. 2014; 25: 2359-81. 10.1007/s00198-014-2794-2. 
4. Curry S, Krist A, Owens D, Barry M, Caughey A et al. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. Jama. Jun 26, 2018; 319: 2521-2531. 10.1001/jama.2018.7498. 
5. Jeremiah M, Unwin B, Greenawald M, Casiano V. Diagnosis and Management of Osteoporosis. Am Fam Physician. Aug 15, 2015; 92: 261-8. 
6. Eastell R, Rosen C, Black D, Cheung A, Murad M. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab. May 1, 2019; 104: 1595-1622. 10.1210/jc.2019-00221. 
7. Shoback D, Rosen C, Black D, Cheung A, Murad M. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020; 105: 587-594. 10.1210/clinem/dgaa048. 
8. Washington State Health Care Authority. WSHCA Health Technology Clinical Committee: 20141121A – Screening & Monitoring Tests for Osteopenia/ Osteoporosis. [Final Adoption: January 16, 2015]. 2015; https://www.hca.wa.gov/assets/program/osteo-final-findings-decision-012715.pdf.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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