Does Your Health Insurance Cover Bone Density?

We have gathered insurance information from the National Osteoporosis Foundation to help you determine if you are eligible for coverage under your current medical plan.

You can begin by checking the chart below. Click any of the underlined links for more detail.

Medicare: Conditions for Reimbursement
Medicare: Denial of Reimbursement
Private Insurers: Denial of Reimbursement

On July 1, 1998, a Medicare law was implemented allowing coverage of bone density tests for five groups of qualified individuals. These five qualified groups include:

• an estrogen deficient woman at clinical risk for osteoporosis;
• an individual with vertebral abnormalities as demonstrated by X-ray to be indicative of osteoporosis, low bone mass or vertebral fracture;
• an individual receiving long-term glucocorticoid (steroid) therapy;
• an individual with primary hyperparathyroidism;
• and an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

Back to Top

Medicare: Conditions For Reimbursement
Certain conditions must be met in order for bone density tests for Medicare beneficiaries to be covered and reimbursed. They include:

• The beneficiary’s treating qualified health care provider must confirm that the patient falls into one of the five categories of individuals qualified to receive the Medicare benefit (see Background above).
• The provider must then order the BMD test based on the fact it is medically necessary. Remember, a test performed without the patient's treating physician ordering the test may result in a repeat test needing to be done. The second test could be denied payment because the first test was already reimbursed. The beneficiary would then have to pay for this second test because Medicare policy generally allows reimbursement for the test every two years. Medicare allows for a follow-up BMD test sooner than two years under certain circumstances. Treating physicians/practitioners many times prefer to specify where they send their patients for tests because they can monitor the quality of the testing facility to be sure high medical standards of test quality are followed.
• The test must be appropriately supervised by a physician.
• The person operating the BMD machine must be appropriately licensed by the State in which the test is done.
• A physician/practitioner order can not be requested after the test is performed. The treating practitioner must order the test in advance.
• If an independent testing enterprise is in business solely to supply tests, no practitioner affiliated with the testing may order the test, unless that practitioner is also regularly treating the beneficiary.
• Some carriers will require the people responsible for performing the BMD test to have a written practitioner order for the test before the test is performed, and will do an audit to assure this requirement is met. The results of the test must then be sent to the referring practitioner for follow-up.

If any of these requirements are not met, the claim is subject to denial of payment and perhaps even repayment. If the beneficiary is directly reimbursed, and these criteria are not met, he/she may also be asked to refund payment.

Back to Top

Medicare: Denial of Reimbursement
If the Medicare carrier does not pay for a bone density test that seems to meet the criteria for coverage, the physician/practitioner can take the following steps: he/she can look up the Medicare carrier's review policy which can be accessed via the web at http://www.lmrp.net under Directories/Contractor Sites at the top of the web page.

The physician/practitioner can also collect the following information:

• Written documentation outlining why a bone density test was recommended.
• Which of the five qualified groups of individuals applies to the beneficiary.
• The ICD-9 codes that were used for the claim.
• A copy of the letter indicating why the Medicare carrier denied coverage for the bone density test.

This documentation should be sent to the local Medicare carrier's office with a cover letter indicating why this coverage decision is not in the best interest of the beneficiary. Medicare carrier information like names, addresses and so forth, can be found on the web at http://www.lmrp.net under Directories/Medicare Part B at the top of the web page. If there is no web access, the blue pages in the phone book can provide direction under United States Government; Health and Human Services, Department of; Centers for Medicare and Medicaid Services.

Often, there will be instructions regarding next steps with the denial of coverage as well. The appeals process should be utilized if there is not a satisfactory decision made by the local Medicare carrier's office. Additional information on the appeals process can be found at http://www.cms.hhs.gov under Professionals/Medicare Health Plans/Appeals and Grievances.

Regional CMS offices can be found on the web at http://www.cms.hhs.gov. On the left-hand side of the web page, select Resources/Contacts. Under Type of Organization, choose CMS RO for CMS Regional Offices and choose the appropriate state.

The Medicare Coverage Advisory Committees (MCAC's) can also be contacted. The purpose of the MCAC's is to advise CMS on whether specific medical items and services are reasonable and necessary under Medicare law. If the local policy is in conflict with national policy, the MCAC may be able to assist. Information about the MCAC's can be found by going to www.cms.hhs.gov. On the left-hand side of the web page, choose Topics/Coverage. Then on the right-hand side of the page under Topics, choose MCAC. Additional information about upcoming MCAC meetings, etc. can be found by selecting Executive Secretary.

Coverage Personnel Directory can also be found by going to www.cms.hhs.gov. Select Topics/Coverage on the left-hand side of the web page. On the right-hand side of the page then choose Topics/Directory.

Back to Top

Private Insurers: Denial of Reimbursement
Reimbursement amounts and coverage criteria for bone density tests performed on people covered with private insurance through employers are variable. There is currently no federal law similar to Medicare that standardizes coverage criteria and reimbursement rates for bone density tests on the private side. Furthermore, the Employee Retirement Income Security Act (ERISA) preempts any state consumer rights laws and bone mass measurement legislation on the state level in most cases.

If there is disagreement about reimbursement or coverage criteria, the appeal/grievance process offered through health plans is one option for providers and consumers. The Medical Director of the health plan can also be contacted once appropriate documentation is in place. Documentation could include such items as why the provider believes a bone density test is necessary, when the test was done, ICD-9 codes used and an explanation of why coverage was denied.

Another option is to contact your state's insurance commissioner with the appropriate documentation to discuss denial of care. A list of commissioners can be found at the website of the National Association of Insurance Commissioners: www.naic.org/1regulator/ under State Insurance Department Health Contacts or under the Map of Insurance Regulators. Administrators also can be contacted to ask that bone density testing be added as a benefit for at-risk individuals through an employer. One health insurance plan can offer many different benefit packages to a variety of employers based on the criteria the employer is using to select a plan for employees.

Individuals and providers can also write their state and federal legislators about their issue. Please include appropriate documentation.

Back to Top

 Contents © Copyright 2008 by 65th Bone Density Center, a subsidiary of Yaffe Ruden & Associates.
 All Rights Reserved.