Question: I recently received a denial on a Medicare claim for a bone density study. The denial cited no medical necessity. If a patient is on hormone replacement therapy, shouldn't a bone density study be covered?
Georgia Subscriber
Answer: Actually, no. A woman is eligible for coverage if she is estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings. Estrogen-deficient means she cannot be on hormone replacement therapy (HRT).
Medicare also covers bone density studies for patients being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy. Unfortunately, HRT is not an FDA-approved osteoporosis drug therapy. Medicare also covers bone density studies for patients who meet the following criteria:
The patient's physician or qualified nonphysician practitioner (this includes a consulting physician or specialist) must provide an order for the bone density study. You could receive a denial if the test was not ordered by one of these entities. If your denial was based on medical necessity, but the patient meets the coverage criteria, Medicare recommends that you contact your state Medicare carrier or intermediary to see what specific diagnosis codes are payable for bone density studies.
As for a patient on HRT, he must also meet one of the other criteria in order to qualify for Medicare coverage.
