Dexa Scan denials in California external review

What the reviewers wrote

Where the denial was overturned

A 57-year-old female enrollee has requested for a DEXA bone density study for evaluation of her bone density. Findings: The physician reviewer found that per the recommendations of the National Osteoporosis Foundation, a baseline DEXA scan should be obtained in women age 50-64 with a family history of osteoporosis. In addition, this patient sustained a foot fracture, although the submitted documentation does not indicate whether the fracture was non-traumatic in origin. Risk factors for osteoporosis include genetic disorders, family history, hormone deficiency, hormone excess, immobilization and microgravity, tobacco abuse, alcoholism, malignancy, medications, and certain systemic diseases. The DEXA scan is used to determine the bone density of the lumbar spine and hips.

The patient is a 52-year-old female requesting a DEXA scan to screen for osteoporosis. Her provider’s progress notes of 9/17/04 indicate the patient’s mother and grandmother had osteoporosis. The patient indicates her grandmother, mother, and sister became aware of osteoporosis after breaking bones and losing height. The Health Plan indicates further information is required before a DEXA scan can be authorized.Screening for osteoporosis in post-menopausal women less than age 60 is recommended by most professional and regulatory authorities if there is at least one risk factor present. Based upon the information provided this patient has at least one risk factor present. Therefore, a screening DEXA scan is medically necessary for evaluation of this patient. As such, I have determined the Health Plan’s denial should be overturned.

Where the denial was upheld

The patient is a 58-year-old woman who has requested authorization and coverage for a bone density evaluation. There is no prior history of fracture or family history of hip fracture. There is no prior history of excess thyroid, long-term steroid use, smoking or any other factor that might suggest an increased risk for a premature fragility fracture. The submitted records indicate the patient stopped taking Premarin as of June 2004. The Health Plan has denied coverage for the requested bone density scan on the basis that it is not medically necessary for evaluation of the patient’s condition.There is some consensus about which post-menopausal women younger than age 65 should be screened for osteoporosis with a DEXA scan.

The patient is a 59-year-old woman who had a diagnosis of low bone mass sometime prior to December 2003. She has been on Fosamax and Evista for an unknown period of time. Two DEXA scans performed in December 2004 and December 2005 revealed stable osteopenia of an undisclosed aspect of her lumbar spine. In a letter dated June 2006 the patient’s provider states that she is having an unspecified “toxic reaction to something in her environment.” He apparently obtained the second scan in preparation for stopping Evista to see if it was the cause of her toxic reaction.It is unknown whether the Evista was indeed stopped after the scan. At issue is whether the repeat DEXA scan in December 2005 was medically necessary.The patient was being treated with Fosamax and Evista for osteopenia of unspecified lumbar vertebrae.

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 Dexa Scan, then check the rights and deadlines that apply to your plan.