NOTE: If medically necessary, Medicare MEDICARE LEARNING NETWORK® (MLN)
may provide coverage for a beneficiary more The Medicare Learning Network® (MLN) is the brand
frequently than every 2 years. Examples of name for official CMS educational products and information
situations in which more frequent bone mass for Medicare Fee-For-Service providers. For additional
measurements may be medically necessary information visit the MLN’s web page at http://www.cms.gov/ DEPARTMENT OF HEALTH AND HUMAN SERVICES
include, but are not limited to, the following medical MLNGenInfo on the CMS website. Centers for Medicare & Medicaid Services
conditions: monitoring patients on long-term
glucocorticoid (steroid) therapy of more than 3
months; or allowing for a confirmatory baseline Your feedback is important to us and we use your
bone density study to permit monitoring in the suggestions to help us improve our educational products,
future if certain specified requirements are met. services and activities that better meet your educational
needs. To evaluate Medicare Learning Network® (MLN)
Medicare provides coverage of bone mass products, services and activities you have participated in, R
measurements as a Part B benefit. The coinsurance received, or downloaded, please go to http://www.cms.gov/
or copayment and deductible apply for the bone mass MLNProducts and click on the link called ‘MLN Opinion
measurement benefit. For dates of service on or after Page’ in the left-hand menu and follow the instructions.
January 1, 2011, both are waived by the Affordable
Care Act. Please send your suggestions related to MLN product topics
or formats to MLN@cms.hhs.gov.
The Centers for Medicare & Medicaid Services (CMS) BENEFICIARY-RELATED INFORMATION
has developed a variety of educational resources as part The official U.S. Government website for people with
of a broad outreach campaign to promote awareness Medicare is located on the web at http://www.medicare.gov,
and increase utilization of preventive services covered or more information can be obtained by calling
by Medicare. 1-800-MEDICARE (1-800-633-4227). TTY users should call
For more information about coverage, coding, billing,
and reimbursement of Medicare-covered preventive This brochure was current at the time it was published or
services and screenings, visit http://www.cms.gov/ uploaded onto the web. Medicare policy changes frequently
MLNProducts/35_PreventiveServices.asp on the CMS so links to the source documents have been provided within
website. the document for your reference.
This brochure was prepared as a service to the public
and is not intended to grant rights or impose obligations.
This brochure may contain references or links to statutes,
regulations, or other policy materials. The information
provided is only intended to be a general summary. It is
not intended to take the place of either the written law or
regulations. We encourage readers to review the specific
statutes, regulations and other interpretive materials for a
full and accurate statement of their contents. For Physicians, Providers, Suppliers,
and Other Health Care Professionals
Official CMS Information for
Medicare Fee-For-Service Providers
ICN 006437 June 2011
The information presented in this ■ A woman who has been
brochure is intended for Medicare Fee- determined by the physician
For-Service physicians, providers, suppliers, or qualified non-physician
and other health care professionals who furnish practitioner treating her to be
or provide referrals for and/or file claims for the estrogen-deficient and at clinical risk
Medicare-covered preventive benefit discussed in this for osteoporosis, based on her medical
brochure. history and other findings.
■ An individual with vertebral abnormalities,
Osteoporosis or “porous bone” is a disease of the skeletal as demonstrated by an X-ray to be indicative
system characterized by low bone mass and deterioration of osteoporosis, osteopenia (low bone
of bone tissue. Osteoporosis produces an enlargement of mass), or vertebral fracture.
the pore spaces in the bone, causing increased fragility and ■ An individual receiving (or expecting to receive)
an increased risk for fracture, typically in the wrist, hip, and glucocorticoid (steroid) therapy equivalent to an
spine. average of 5.0 mg of prednisone or greater per
day for more than 3 months.
An estimated 10 million Americans have osteoporosis ■ An individual with known primary
and more than 34 million Americans have low bone mass, hyperparathyroidism; or
placing them at increased risk for osteoporosis. One out of ■ An individual being monitored to assess the
every two women and one in four men aged 50 and older To ensure accurate measurement and consistent test response to, or efficacy of, an FDA-approved
will have an osteoporosis-related fracture in their lifetime. results, bone density studies for periodic follow-up tests osteoporosis drug therapy.
should generally be performed on the same suitably precise 2) The physician or qualified non-physician
The good news is that osteoporosis is a preventable instrument, and results should be obtained from the same practitioner treating the qualified individual
and treatable disease. Early diagnosis and treatment scanner when comparing a patient to a control population. must provide an order for a bone mass
can reduce or prevent fractures. Medicare’s bone mass measurement test, following an evaluation of the
measurement benefit can aid in the early detection of RISK FACTORS need for a bone mass measurement that
osteoporosis before fractures happen, provide a precursor Osteoporosis can develop in anyone; however, some risk included a determination of the medically
to future fractures, and determine the rate of bone loss. factors for developing osteoporosis included the following: appropriate measurement for the individual.
■ Age 50 or older, 3) The service must be a radiologic or radioisotopic
BONE MASS MEASUREMENT DEFINED ■ Female gender, procedure (or other procedure) meets the
“Bone mass measurement,” also known as “bone density ■ Family history of broken bones, following requirements:
study,” is a radiological or radioisotope procedure or other ■ Personal history of broken bones, ■ Is performed with a bone densitometer (other than
procedure approved by the Food and Drug Administration ■ Caucasian or Asian-American ethnicity, dual photon absorptiometry) or a bone sonometer
(FDA). It identifies bone mass, detects bone loss, or ■ Small bone structure, (e.g., ultrasound) device approved or cleared for
determines bone quality. Bone mass measurements ■ Low body weight (less than 127 pounds), marketing by the FDA;
evaluate bone disease and/or responses of treatment; ■ Frequent smoking or drinking, and ■ Is performed for the purpose of identifying bone
they include a physician’s interpretation of the procedure’s ■ Low-calcium diet. mass, detecting bone loss, or determining bone
results. The studies assess bone mass or density quality; and
associated with osteoporosis and other bone abnormalities. IMPORTANT NOTE: Although risk factors may put ■ Includes a physician’s interpretation of the
some individuals at increased risk for developing procedure’s results.
METHODS OF BONE MASS MEASUREMENTS osteoporosis, Medicare does not provide coverage of 4) A qualified supplier or provider must furnish such
Bone density is usually studied using diagnostic bone bone mass measurement for all beneficiaries in these services under the appropriate level of supervision
mass measurement techniques recognized by the FDA. high risk groups. Medicare provides coverage for bone by a physician.
Bone density can be measured at the wrist, spine, hip, or mass measurements for qualified beneficiaries when 5) The service must be reasonable and medically
calcaneus (heel). Single and combined measurements all of the benefit coverage criteria described in the necessary to diagnose, treat, or monitor a qualified
may be required to diagnose bone disease, monitor Coverage Information section are met. individual.
bone changes with disease progression, or monitor bone 6) The service must be performed at a frequency
changes with therapy. COVERAGE INFORMATION that conforms to the Frequency Requirements
Medicare’s bone mass measurement benefit includes a section.
Medicare provides coverage for the following physician’s interpretation of the procedure’s results.
densitometers: Medicare provides coverage of bone mass measurements FREQUENCY REQUIREMENTS
■ A stationary device permanently located in an that meet coverage criteria 1-6 below: Medicare provides coverage of a bone mass measurement
office, that meets the criteria described above once every 2 years
■ A mobile device transported by vehicle from site 1) The bone mass measurement is performed on (i.e., at least 23 months after the last covered bone mass
to site, and a qualified individual. A “qualified individual” means a measurement was performed).
■ A portable device picked up and moved from one Medicare beneficiary who meets the medical indications
site to another. for at least one of the following categories: