BMM means a radiologic, radioisotopic, or other procedure that meets all of the following conditions:
• Is performed to identify bone mass, detect bone loss, or determine bone quality.
• Is performed with either a bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under 21 CFR part 814.
• Includes a physician’s interpretation of the results.
Conditions for Coverage
Medicare covers BMM under the following conditions:
1. Is ordered by the physician or qualified nonphysician practitioner who is treating the beneficiary following an evaluation of the need for a BMM and determination of the appropriate BMM to be used.
A physician or qualified nonphysician practitioner treating the beneficiary for purposes of this provision is one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in the management of the patient. For the purposes of the BMM benefit, qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives.
2. Is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b).
3. Is reasonable and necessary for diagnosing and treating the condition of a beneficiary who meets the conditions described in §80.5.6.
4. In the case of an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, is performed with a dual-energy x-ray absorptiometry system (axial skeleton).
5. In the case of any individual who meets the conditions of 80.5.6 and who has a confirmatory BMM, is performed by a dual-energy x-ray absorptiometry system (axial skeleton) if the initial BMM was not performed by a dual-energy x-ray absorptiometry system (axial skeleton). A confirmatory baseline BMM is not covered
if the initial BMM was performed by a dual-energy x-ray absorptiometry system (axial skeleton).
Medicare pays for a screening BMM once every 2 years (at least 23 months have passed since the month the last covered BMM was performed).
When medically necessary, Medicare may pay for more frequent BMMs. Examples include, but are not limited to, the following medical circumstances:
• Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months.
• Confirming baseline BMMs to permit monitoring of beneficiaries in the future.