Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA)

Description of Procedure or Service

Vertebral fracture assessment (VFA) with densitometry is a technique in which vertebral fractures are assessed at the same time as bone mineral density (BMD), using additional software with dual-energy x-ray absorptiometry (DXA). The addition of vertebral fractures to BMD may provide additional useful information on a subject’s risk of fracture.

Vertebral fractures are highly prevalent in the elderly population, and epidemiologic studies have found that these fractures are associated with an increased risk of future spine or hip fractures independent of bone mineral density.

Only 20%-30% of vertebral fractures are recognized clinically; the rest are discovered incidentally on lateral spine radiographs. Lateral spine x-rays have not been recommended as a component of risk assessment for osteoporosis, because of the cost, radiation exposure, and the fact that the x-ray would require a separate procedure in addition to the bone mineral density study using dual x-ray absorptiometry (DXA). However, several densitometers with specialized software are able to perform vertebral fracture assessment (VFA) in conjunction with DXA. The lateral spine scan is performed using a rotating arm; depending on the densitometer used, the patient can either stay in the supine position after the bone density study or is required to move onto the left decubitus position.

VFA differs from radiological detection of fractures, as VFA uses a lower radiation exposure and can detect only fractures, while traditional x-ray images can detect other bone and soft tissue abnormalities in addition to spinal fractures. Manufacturers have also referred to this procedure as instant vertebral assessment, radiographic vertebral assessment, dual energy vertebral assessment or lateral vertebral assessment.

For both lateral spine radiographs and images with densitometry, vertebral fractures are assessed visually. A number of grading systems have been proposed, and the Genant semiquantitative method is commonly used. This system grades deformities from I to III, with grade I (mild) representing a 20% to 24% reduction in vertebral height, grade II (moderate) representing a 25% to 39% reduction in height, and grade III (severe) representing a 40% or greater reduction in height. The location of the deformity within the vertebrae may also be noted. For example, if only the mid-height of the vertebrae is affected, the deformity is defined as an endplate deformity; if both the anterior and mid-heights are deformed, it is a wedge deformity; and if the entire vertebrae is deformed, it is classed as a crush deformity. A vertebral deformity of at least 20% loss in height is typically considered a fracture. Accurate interpretation of both lateral spine radiographs and VFA imaging depends on radiologic training. Thus, device location and availability of appropriately trained personnel may influence diagnostic accuracy.

Regulatory Status

To perform vertebral fracture assessment with a densitometer, additional software is needed, and it must have 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA).

Related Policies

Bone Turnover Markers Testing

Bone Mineral Density Studies

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

Screening for vertebral fractures using dual energy x-ray absorptiometry (DXA) is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) is covered

Not applicable

When Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) is not covered

Screening for vertebral fractures using dual energy x-ray absorptiometry (DXA) is considered investigational. BCBSNC does not provide coverage for investigational services or procedures.

Policy Guidelines

For individuals who are at risk of having vertebral fractures but are not known to have them who receive vertebral fracture assessment (VFA) with densitometry by dual-energy x-ray absorptiometry (DXA), the evidence includes diagnostic accuracy studies and subanalyses of treatment studies. Relevant outcomes are test accuracy and validity, morbid events, and resource utilization. There is a lack of direct evidence from screening trials that use of densitometry with and without VFA improves health outcomes. Because direct evidence was not available, a causal chain of indirect evidence was sought. Evidence was examined on the diagnostic accuracy of VFA in nonosteoporotic patients (i.e., those not already eligible for treatment), the ability of VFA to identify patients for treatment who would not otherwise be identified, and the effectiveness of treatment in this population. Diagnostic accuracy studies have variable findings; recent studies have suggested higher diagnostic accuracy of VFA overall compared with standard radiographs than older studies. Studies have found that VFA can identify patients without osteoporosis who may be appropriate candidates for treatment according to recommendations from the National Osteoporosis Foundation (NOF). However, there is limited evidence on the effectiveness of treatment in this population. No treatment data have been published in patients whose vertebral fracture had been identified using VFA software with densitometry. The evidence is insufficient to determine the effects of the technology on health outcomes.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page

Applicable service codes: 77085, 77086, 0691T

Scientific Background and Reference Sources

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 12/14/05

BCBSA TEC Assessment. Screening for Vertebral Fracture with Dual X-ray Absorptiometry (February 2006)

Centers for Medicare & Medicaid Services. Local Coverage Determination for Bone (Mineral) Density Studies (L957). Retrieved September 11, 2006

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 4/17/07

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 1/13/11

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 1/12/12

Specialty Matched Consultant Advisory Panel, 6/2012

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 1/10/13

Specialty Matched Consultant Advisory Panel, 7/2013

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 1/9/14

National Osteoporosis Foundation. The Clinician's Guide to Prevention and Treatment of Osteoporosis 2014. Last accessed June 2014.

Specialty Matched Consultant Advisory Panel, 7/2014

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 5/22/14

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 5/21/15

Specialty Matched Consultant Advisory Panel review- 6/2015

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 9/8/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 9/14/2017

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 9/13/2018

Specialty Matched Consultant Advisory Panel - 5/2020

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 9/12/2019

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.44, 9/10/2020

Specialty Matched Consultant Advisory Panel - 5/2021

Medical Director review 5/2021

U.S. Preventive Services Task Force. Osteoporosis to Prevent Fractures: Screening. 2018

Specialty Matched Consultant Advisory Panel - 5/2022

Medical Director review 5/2022

Specialty Matched Consultant Advisory Panel - 5/2023

Medical Director review 5/2023

Alsoof D, Anderson G, McDonald CL, et al. Diagnosis and Management of Vertebral Compression Fracture. Am J Med. Jul 2022; 135(7): 815-821. PMID 35307360

Specialty Matched Consultant Advisory Panel - 5/2024

Medical Director review 5/2024

Policy Implementation/Update Information

12/9/14 Converted from Evidence Based Guideline to Corporate Medical Policy. Screening for vertebral fractures using dual energy x-ray absorptiometry (DEXA or DXA) is considered investigational. Changed DEXA to DXA in the title of the policy. Deleted CPT code 77082 and added CPT codes 77085 and 77086 to the Billing/Coding section for effective date 1/1/2015. Policy noticed 12/9/14 for effective date 2/10/15. (lpr)

7/28/15 Specialty Matched Consultant Advisory Panel review 6/24/2015. Reference added. No change to policy statement. (lpr)

7/26/16 References updated. Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement. (an)

6/30/17 Policy Guidelines updated. Added reference. Specialty Matched Consultant Advisory Panel review 5/26/2017. No change to policy statement. (an)

6/29/18 Reference updated. Specialty Matched Consultant Advisory Panel review 5/23/2018. No change to policy statement. (an)

6/11/19 Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019. No change to policy statement. (an)

6/9/20 Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement. (eel)

6/1/21 Reference added. Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021. No change to policy statement. (bb)

12/30/21 The following code was added to the Billing/Coding section: 0691T effective 1/1/2022. (tt)

5/31/22 Related policies updated. References added. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director review 5/2022. No change to policy statement. (tt)

5/30/23 Description and regulatory status updated. References added. Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director review 5/2023. No change to policy statement. (tt)

5/29/24 References added. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. No change to policy statement. (tt)