Dual-energy X-ray Absorptiometry denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a dual-energy X-ray absorptiometry (DXA) bone density study (CPT 77085).Findings: Three out of three physician reviewers found that the services at issue were likely to have been more beneficial than any other available standard treatments for the enrollee’s medical condition.The American College of Radiology (ACR) has established Appropriateness Criteria to help guide referring practitioners in their most efficient and efficacious use of imaging for various clinical presentations. In their guidelines for osteoporosis screening or initial imaging of clinically suspected low bone mineral density (Variant 1), a DEXA scan is identified as a first line study and assigned the Appropriateness Category of “Usually Appropriate”.

Nature of Statutory Criteria/Case Summary: The patient is a 59-year-old female with a history of osteoporosis. Findings: The physician reviewer found that bone densitometry of the hip and lumbar spine revealed a hip T-score of -2.2 and lumbar spine T-score of -2.8. The bone mineral density of the left hip was noted to be osteopenic, and the bone mineral density of the lumbar spine was noted to be osteoporotic. In a letter, the patient’s provider noted a bone density test in 2017 revealed osteoporosis of the lumbar spine, and the left hip was osteopenic. The patient had previously been treated with Evista. She has requested authorization and coverage for a bone density test (dual energy x-ray absorptiometry, also called DEXA scan). The Health Plan denied the request and reported that the requested services are not medically necessary for the evaluation of this patient.

Where the denial was upheld

A 51-year-old female has requested coverage for a bone density scan/dual energy x-ray absorptiometry (DEXA) scan for evaluation of her bone pain. Findings: The physician reviewer found that the record provided for review does not establish that this patient is at risk for osteoporosis. Pain alone is not an indication of osteoporosis or bone loss. The patient is 51-years-old and there is no documentation that she is in menopause or has any other form of estrogen deficiency. Her comprehensive metabolic panel, including calcium, kidney function, and complete blood count (CBC) are all normal. The patient has diabetes but this is reportedly well controlled. In addition, the patient has no history of fractures or history of glucocorticoid use.

A 51-year-old female has requested coverage for a bone density scan/dual energy x-ray absorptiometry (DEXA) scan for evaluation of her bone pain. Findings: The physician reviewer found that the record provided for review does not establish that this patient is at risk for osteoporosis. Pain alone is not an indication of osteoporosis or bone loss. The patient is 51-years-old and there is no documentation that she is in menopause or has any other form of estrogen deficiency. Her comprehensive metabolic panel, including calcium, kidney function, and complete blood count (CBC) are all normal. The patient has diabetes but this is reportedly well controlled. In addition, the patient has no history of fractures or history of glucocorticoid use.

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 Dual-energy X-ray Absorptiometry, then check the rights and deadlines that apply to your plan.