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PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: OSTEOPOROSIS SCREENING IN WOMEN
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Description:
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The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010. The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
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Policy/
Coverage:
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Screening for osteoporosis is covered for members of “non-grandfathered” plans, no more than once every 2 years, without cost-sharing (i.e., deductible, co-insurance, or co-pay):
- in women aged 65 years of age or older
- In women under the age of 65 years who have an increased risk of osteoporotic fractures. Increased risk is defined as a woman with a risk of fracture equal to or greater than the risk of a 65 year old white woman with no additional risk (i.e., 9.3%). Risk is determined by the FRAX Score.
The FRAX score does not include risk factors such as the long-term use of certain drugs which have been associated with increased risk of osteoporosis, and the USPSTF recommendation for osteoporosis screening does not specifically address the risk of pharmaceuticals. However, bone mineral density screening of women who are expected to receive long-term use of the following drugs is also covered:
- Oral or injectable glucocorticosteroids (at a dose of prednisolone of 5 mg/day (or equivalent dose of another corticosteroid) for 3 months).
- Heparin if scheduled for >1 month.
- Phenytoin
- Aromatase inhibitors
- Gonadotropin releasing hormone antagonists
- Cyclosporin A
- Tacrolimus
- Parenteral Nutrition
This policy does not apply to individuals with a diagnosis of osteoporosis. Bone Mineral Density testing in individuals with a diagnosis of osteoporosis is handled in policy # 1997054, Bone Mineral Density Testing in Women.
The appropriate ICD-10 code to report this service is Z13.820.
CPT Code 77080 may be used to report this service. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
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Rationale:
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The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors (Grade B recommendation).
- This recommendation applies to older adults in the general U.S. population who do not have a history of an osteoporotic fracture, osteoporosis secondary to another condition, or other specific clinical indications for bone measurement testing. The USPSTF did not define a specific upper age limit for screening in women because the risk for fractures continues to increase with age and treatment harms remain no greater than small. Clinicians should take into account the patient's remaining lifespan when deciding whether to screen patients with significant illness. In the Fracture Intervention Trial, the benefit of treatment emerged 18 to 24 months after initiation of treatment.
- The quantity and quality of data on osteoporotic fracture risk other than hip fracture are much less for Asian, American Indian or Alaska Native, Hispanic, and black women than for white women. The USPSTF's recommendation to screen women aged 65 years or older for osteoporosis applies to all racial and ethnic groups because the harms of the screening tests are no greater than small, the consequences of failing to identify and treat women who have low bone mineral density (BMD) are considerable, and the optimal alternative age at which to screen nonwhite women is uncertain.
- Multiple instruments to predict risk for low BMD and fractures have been developed and validated for use in postmenopausal women, but few have been validated for use in men. To predict fracture risk, the area under the receiver-operating characteristic curve ranges from 0.48 to 0.89. Less complex instruments (that is, those with fewer variables) seem to perform as well as more complex ones. The USPSTF found no studies that assessed the effect on patient outcomes of using risk prediction instruments alone or in combination with bone measurement tests.
- The USPSTF used the FRAX (Fracture Risk Assessment) tool (World Health Organization Collaborating Centre for Metabolic Bone Diseases, Sheffield, United Kingdom), available at www.shef.ac.uk/FRAX/ , to estimate 10-year risks for fractures because this tool relies on easily obtainable clinical information, such as age, body mass index (BMI), parental fracture history, and tobacco and alcohol use; its development was supported by a broad international collaboration and extensively validated in 2 large U.S. cohorts; and it is freely accessible to clinicians and the public. The FRAX tool includes questions about previous DXA results but does not require this information to estimate fracture risk.
- Based on the U.S. FRAX tool, a 65-year-old white woman with no other risk factors has a 9.3% 10-year risk for any osteoporotic fracture. White women between the ages of 50 and 64 years with equivalent or greater 10-year fracture risks based on specific risk factors include but are not limited to the following persons: 1) a 50-year-old current smoker with a BMI less than 21 kg/m2, daily alcohol use, and parental fracture history; 2) a 55-year-old woman with a parental fracture history; 3) a 60-year-old woman with a BMI less than 21 kg/m2 and daily alcohol use; and 4) a 60-year-old current smoker with daily alcohol use. The FRAX tool also predicts 10-year fracture risks for black, Asian, and Hispanic women in the United States. In general, estimated fracture risks in nonwhite women are lower than those for white women of the same age.
- Although the USPSTF recommends using a 9.3% 10-year fracture risk threshold to screen women aged 50 to 64 years, clinicians also should consider each patient's values and preferences and use clinical judgment when discussing screening with women in this age group. Menopausal status is one factor that may affect a decision about screening in this age group.
- The most commonly used bone measurement tests used to screen for osteoporosis are DXA of the hip and lumbar spine and quantitative ultrasonography of the calcaneus. Quantitative ultrasonography is less expensive and more portable than DXA and does not expose patients to ionizing radiation. Quantitative ultrasonography of the calcaneus predicts fractures of the femoral neck, hip, and spine as effectively as DXA. However, current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only, and criteria based on quantitative ultrasonography or a combination of quantitative ultrasonography and DXA have not been defined.
- The potential value of rescreening women whose initial screening test did not detect osteoporosis is to improve fracture risk prediction. A lack of evidence exists about optimal intervals for repeated screening and whether repeated screening is necessary in a woman with normal BMD. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in BMD; however, longer intervals may be necessary to improve fracture risk prediction. A prospective study of 4,124 women aged 65 years or older found that neither repeated BMD measurement nor the change in BMD after 8 years was more predictive of subsequent fracture risk than the original measurement.
- Given the absence of direct evidence that screening for osteoporosis reduces fracture-related morbidity or mortality, studies of long-term health outcomes of screened and nonscreened population groups are important. Research is needed to test the effectiveness of drug therapies for osteoporosis in men who do not have a history of fractures. The results of ongoing randomized trials of bisphosphonates for fracture prevention in men at high risk for fractures could help to assess whether these drugs are effective in men. Research to evaluate the outcome of screening women during periods of rapid bone loss (for example, during menopause) also should be supported.
- Further research that would inform clinical decisions about screening for osteoporosis include studies to establish parameters for treatment using quantitative ultrasonography as a primary screening test for osteoporosis, studies that ascertain the true incidence of major osteoporotic fractures in nonwhite ethnic groups in the United States, studies clarifying optimal screening intervals, and studies of the effect of clinical and subclinical vertebral fractures on health-related quality of life.
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CPT/HCPCS:
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References:
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PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act.
Screening for Osteoporosis. U.S. Preventive Services Task Force.
Screening for Osteoporosis.(2011) U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm. Last accessed May 2011.
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Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association.
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