Page 113 - Medicare Benefit Policy Manual

410.31. Denials as not reasonable and necessary can be found at §1862(a)(1)(A) of the
Act, 42 CFR 410.31(e), and 42 CFR 411.15(k).

80.5.3 - Definition
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)

BMM means a radiologic, radioisotopic, or other procedure that meets all of the
following conditions:

• Is performed to identify bone mass, detect bone loss, or determine bone
quality.

• Is performed with either a bone densitometer (other than single-photon or
dual-photon absorptiometry) or a bone sonometer system that has been cleared
for marketing for BMM by the Food and Drug Administration (FDA) under
21 CFR part 807, or approved for marketing under 21 CFR part 814.

• Includes a physician’s interpretation of the results.

80.5.4 - Conditions for Coverage
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)

Medicare covers BMM under the following conditions:

1. Is ordered by the physician or qualified nonphysician practitioner who is treating the
beneficiary following an evaluation of the need for a BMM and determination of the
appropriate BMM to be used.

A physician or qualified nonphysician practitioner treating the beneficiary for
purposes of this provision is one who furnishes a consultation or treats a beneficiary
for a specific medical problem, and who uses the results in the management of the
patient. For the purposes of the BMM benefit, qualified nonphysician practitioners
include physician assistants, nurse practitioners, clinical nurse specialists, and
certified nurse midwives.

2. Is performed under the appropriate level of physician supervision as defined in 42
CFR 410.32(b).

3. Is reasonable and necessary for diagnosing and treating the condition of a beneficiary
who meets the conditions described in §80.5.6.

4. In the case of an individual being monitored to assess the response to or efficacy of an
FDA-approved osteoporosis drug therapy, is performed with a dual-energy x-ray
absorptiometry system (axial skeleton).