REVIEW REQUEST FOR
Central (Hip or Spine) Bone Density Measurement
and Screening for Vertebral Fractures Using Dual Energy
X-Ray Absorptiometry
Provider Data Collection Tool Based on Policy 6.01.01; Clinical Guideline CG-MED-39
Policy Last Review Date: 12/7/2011; 11/17/2011
Policy Effective Date: 01/01/2012; 01/11/2012
Provider Tool Effective Date: 03/09/2012
Member Name:
Date of Birth:
Insurance Identification Number:
Member Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the member:
The request is for (check all that apply):
The request is for a baseline, central (hip and/or spine) bone density measurement
The request is for a repeat or follow-up central bone density measurement
The request is for a central bone density measurement using the spine (trabecular bone), and/or hip (mixed cortical and
trabecular bone)
The request is for routine screening for osteoporosis or osteoporosis risk
The request is for screening for vertebral fractures using dual x-ray absorptiometry as an adjunct to bone mineral density
measurement
The member has any of the following conditions/situations (check all that apply):
The member is postmenopausal
The member is menopausal
The member (male or female) is with clinical evidence of vertebral osteoprosis as indicated by any of the following:
Decrease in height of > 1.5 inches
Presence of kyphosis
X-ray identification of vertebral compression fractures, osteoprosis, or ostepenia
The member is not on therapy for osteoporosis
The member is on therapy for osteoporosis
The member is without significant osteopenia or not at high risk for accelerated bone loss and it has been at least 3
years since the last bone density study.
The member has had an initial bone density measurement well above the minimal desirable level
The member has significant osteopenia or is at high risk for accelerated bone loss and it has been at least 2 years since the
last bone density study.
The test will be used to monitor the response to therapy, and it has been at least 2 years since the last bone density study.
The member has asymptomatic primary hyperparathyroidism and the bone density level will determine consideration for
surgery
The member is receiving long-term glucocorticoid therapy equal to or greater than 7.5 mg/day of prednisone, for 3 months
or longer and intervention is an option
Other:
Does the documentation support that the member has or is suspected to have any of the following conditions:
Anorexia nervosa
Lupron therapy in men
Calcitonin deficiency
Malabsorption syndromes
Chronic liver disease
Malignancies (multiple myeloma)
Chronic renal failure
Organ transplantation
Chronic use of anti-convulsants (particularly Dilantin)
Osteogenesis imperfecta
Chronic use of heparin
Prolonged amenorrhea (6 months or longer)
Cushing’s syndrome
Prolonged immobilization
Fragility or pathologic fracture
Radiologic evidence of osteopenia
Hypersecrection of calcitonin
Receiving aromatase inhibitor thereapy
Hypercalciuria
Receiving chemotherapeutic agents which affect bone
Hyperthryoidism
density
Hypothyroidism
Rheumatoid arthritis
Hypogonadism
Untreated premature menopause
Inflammatory bowel disease
Vertebral abnormalities
Other:
Codes
Procedure Code(s):____________________________
Diagnosis Code (s):____________________________
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
By checking this box, I attest the information provided is true and accurate to the best of my knowledge. I understand that
Anthem may perform a routine audit and request the medical documentation to verify the accuracy of the information reported
on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Page 2 of 2