[Code of Federal Regulations] [Title 42, Volume 2] [Revised as of October 1, 2005] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR410.31] [Page 327-328] TITLE 42--PUBLIC HEALTH CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 410_SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS--Table of Contents Subpart B_Medical and Other Health Services Sec. 410.31 Bone mass measurement: Conditions for coverage and frequency standards. (a) Definition. As used in this section unless specified otherwise, the following definition applies: Bone mass measurement means a radiologic, radioisotopic, or other procedure that meets the following conditions: (1) Is performed for the purpose of identifying bone mass, detecting bone loss, or determining bone quality. (2) Is performed with either a bone densitometer (other than dual- photon absorptiometry) or with a bone sonometer system that has been cleared for marketing for this use by the FDA under 21 CFR part 807, or approved for marketing by the FDA for this use under 21 CFR part 814. (3) Includes a physician's interpretation of the results of the procedure. (b) Conditions for coverage. Medicare covers a medically necessary bone mass measurement if the following conditions are met: (1) Following an evaluation of the beneficiary's need for the measurement, including a determination as to the medically appropriate procedure to be used for the beneficiary, it is ordered by the physician or a qualified nonphysician practitioner (as these terms are defined in Sec. 410.32(a)) treating the beneficiary. (2) It is performed under the appropriate level of supervision of a physician (as set forth in Sec. 410.32(b)). (3) It is reasonable and necessary for diagnosing, treating, or monitoring the condition of a beneficiary who meets the conditions described in paragraph (d) of this section. (c) Standards on frequency of coverage--(1) General rule. Except as allowed under paragraph (c)(2) of this section, Medicare may cover a bone mass measurement for a beneficiary if at least 23 months have passed since the month the last bone mass measurement was performed. (2) Exception. If medically necessary, Medicare may cover a bone mass measurement for a beneficiary more frequently than allowed under paragraph (c)(1) of this section. Examples of situations where more frequent bone mass measurement procedures may be medically necessary include, but are not limited to, the following medical circumstances: (i) Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months. (ii) Allowing for a confirmatory baseline bone mass measurement (either central or peripheral) to permit monitoring of beneficiaries in the future if the initial test was performed with a technique that is different from the proposed monitoring method. (d) Beneficiaries who may be covered. The following categories of beneficiaries may receive Medicare coverage for a medically necessary bone mass measurement: (1) A woman who has been determined by the physician (or a qualified nonphysician practitioner) treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings. (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 7.5 mg of prednisone, or greater, per day for more than 3 months. (4) An individual with primary hyperparathyroidism. (5) An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy. (e) Denial as not reasonable and necessary. If CMS determines that a bone [[Page 328]] mass measurement does not meet the conditions for coverage in paragraphs (b) or (d) of this section, or the standards on frequency of coverage in paragraph (c) of this section, it is excluded from Medicare coverage as not ``reasonable'' and ``necessary'' under section 1862(a)(1)(A) of the Act and Sec. 411.15(k) of this chapter. [63 FR 34327, June 24, 1998]