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 Clinical Guideline CG-MED-39
Policy Last Review Date: 11/05/2015
Policy Effective Date: 01/05/2016
Provider Tool Effective Date: 01/01/2015
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s 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 Code(s) (if known):
NOTE: This provider tool addresses requests for central bone mineral density (BMD) measurements and vertebral
fracture assessment using dual energy X-Ray absorptiometry (DEXA). This tool does not address peripheral (for example.
forearm, finger, and heel) bone density measurements or bone density testing by computed tomography.
Please check all that apply to the individual:
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 individual has any of the following conditions/situations (check all that apply):
The individual is postmenopausal
The individual is menopausal
The individual (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 individual is not on therapy for osteoporosis
The individual is on therapy for osteoporosis
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 Clinical Guideline CG-MED-39
Policy Last Review Date: 11/05/2015
Policy Effective Date: 01/05/2016
Provider Tool Effective Date: 01/01/2015
The individual 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 individual has had an initial bone density measurement well above the minimal desirable level
The individual 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 individual has asymptomatic primary hyperparathyroidism and the bone density level will determine consideration for
surgery
The individual 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 individual has or is suspected of having 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:
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees 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 and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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