Page 114 - Medicare Benefit Policy Manual

5. In the case of any individual who meets the conditions of 80.5.6 and who has a
confirmatory BMM, is performed by a dual-energy x-ray absorptiometry system
(axial skeleton) if the initial BMM was not performed by a dual-energy x-ray
absorptiometry system (axial skeleton). A confirmatory baseline BMM is not
covered if the initial BMM was performed by a dual-energy x-ray absorptiometry
system (axial skeleton).

80.5.5 - Frequency Standards
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)

Medicare pays for a screening BMM once every 2 years (at least 23 months have passed
since the month the last covered BMM was performed).

When medically necessary, Medicare may pay for more frequent BMMs. Examples
include, but are not limited to, the following medical circumstances:

• Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of
more than 3 months.

• Confirming baseline BMMs to permit monitoring of beneficiaries in the
future.

80.5.6 - Beneficiaries Who May be Covered
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)

To be covered, a beneficiary must meet at least one of the five conditions listed below:

1. A woman who has been determined by the physician or qualified nonphysician
practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis,
based on her medical history and other findings.

NOTE: Since not every woman who has been prescribed estrogen replacement
therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a
woman is receiving ERT should not preclude her treating physician or other qualified
treating nonphysician practitioner from ordering a bone mass measurement for her. If
a BMM is ordered for a woman following a careful evaluation of her medical need,
however, it is expected that the ordering treating physician (or other qualified treating
nonphysician practitioner) will document in her medical record why he or she
believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.

2. An individual with vertebral abnormalities as demonstrated by an x-ray to be
indicative of osteoporosis, osteopenia, or vertebral fracture.

3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy
equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3
months.