Medicare Bone Mass Measurement Coverage Standardization Act

By Ronald L. Scott
rscott@central.uh.edu

Effective July 1, bone mineral density (BMD) testing is added to the list of procedures for which Medicare will pay. BMD tests help physicians determine the status of a patient’s bone health to better predict the risk of future fractures due to osteoporosis, a progressive bone-thinning disease. BMD tests use low-dosage radiation to determine the bone density of the spine and hip. The results are presented in standard deviations (SDs) from the population at large or control groups. BMD reports designate the SDs in the form of "T" scores (SDs from the normal young adult mean) and "Z" scores (which represent the SDs from age-and sex-matched control subjects). World Health Organization guidelines define osteoporosis as a BMD value –2.5 SD or greater below the young adult mean. Physicians may also initiate preventive intervention or therapy based on factors other than test results, such as the presence of low-trauma fractures. With greater awareness of the benefits of BMD testing, people may soon be comparing and discussing their T and Z scores the way people now discuss levels of "good" and "bad" cholesterol.

Patients with osteoporosis are much more likely to experience hip fractures. Such fractures, although highly preventable, may be devastating from both a personal and public health standpoint. About 250,000 hip fractures occur annually in the United States, and the mortality rate for persons in the U.S. Medicare population who sustain such fractures is 24% at 12 months. Of those that survive after one year, only 54% can walk unaided and only 40% can independently perform all physical activities of daily living.

Successive BMD tests can determine the rate of increase or decrease in bone mass to test the efficacy of treatment. Medicare reimbursement guidelines allow BMD tests every two years, and more often if medically necessary. Some states mandate that insurers offer coverage for bone mass measurement. For example, Texas requires that all group health insurance policies provide testing for certain qualified individuals, including all postmenopausal women who are not receiving estrogen replacement therapy, individuals with vertebral abnormalities, or a history of bone fractures. Hormone replacement therapy in postmenopausal women reduces the incidence and severity of osteoporosis. Opponents of broad testing or screening argue that bone density testing is not medically necessary to determine if postmenopausal hormone replacement therapy is necessary. The cost of testing is $150-$175 for the most common and effective tests, and opponents argue that providing testing only for those medically at-risk is more efficient and cost effective. Proponents of testing believe that women will be able to determine at an early stage whether they have osteoporosis and be able to take corrective action. A less sophisticated ultrasound test costing about $15 may be sufficient for screening purposes, and could shift the cost-benefit analysis in favor of broader testing/screening.

07/17/98