Bone Density Scan denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested peripheral bone mineral density (BMD) testing and breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy. Breast tomosynthesis is U.S. Food and Drug Administration (FDA) approved as an adjuvant method of screening along with traditional mammography. In the screening setting, tomosynthesis helps to decrease recall rates by delineating true lesions from spurious lesions caused by overlapping structures seen on routine mammography.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bone density study. According researchers guidelines, bone density screening is recommended for postmenopausal women under age 65 with one risk factor. The detection of subclinical vertebral fractures using dual-energy x-ray absorptiometry (DEXA) vertebral fracture assessment is well established across current medical literature as results may alter clinical management. Recommendations for postmenopausal women over age 50 may include fracture, height loss, or glucocorticoid treatment. Other criteria include osteopenia and two or more of the following: being aged 60 to 69 years old, self-reported nonvertebral fractures, height loss, and chronic diseases associated with an increased risk of vertebral fractures.

Where the denial was upheld

A 41-year-old female enrollee has requested CPT codes, 99215, 36415, 76977, 82270 X 3, 82365, 82397 x 122, 99000, 99001, 93720, 93922 x 2, 94010 x 2, A4649 x 4, A4556NU, A4617NU X 2, A4927NU, 99214, and 82365, for evaluation of her medical condition. Findings: The physician reviewer found that with regard to CPT code 76977 (bone mass screening by ultrasound), this study was not medically necessary in a patient of this patient’s age without a history of hyperparathyroidism. In addition, there were no clinical indications for CPT code 82365 (infrared spectroscopy) based on the documentation provided. CPT code 82397 (chemoluminescence), is not within the standard of care in this particular setting and thus was not medically necessary. CPT code 93720 (body plethysmography) is indicated for patients who have air spaces within the lung that do not communicate with the bronchial tree.

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for peripheral bone density testing for possible osteoporosis. Findings: The physician reviewer found that There is a lack of support for the superior efficacy of the services at issue in this clinical setting. While the heel bone density screening test may be good at predicting fracture risk and is a reasonable test when trying to assess the patient’s risk factors for low bone mineral density (BMD), this test is not likely to be more beneficial than the available standard methods of assessing BMD risk. The medical literature show evidence that dual-energy x-ray absorptiometry (DXA, DEXA) scan of the hip yields better results when assessing for future risk fracture.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Bone Density Scan, then check the rights and deadlines that apply to your plan.