Coverage of Conditions and Treatments (Coverage Decisions)

Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.

List also available in PDF format.

See Treatment Guidelines and Resources for additional information.

Dual X-ray absorptiometry (DXA) is the standard technology for measuring bone mineral density and diagnosing osteopenia or osteoporosis

Bone mineral density testing with dual x-ray absorptiometry (DXA) is a covered benefit with conditions.

Conditions of Coverage

Initial Screening:

Asymptomatic women

  • Women ≥ 65,
    Or
  • Younger women with equivalent ten year fracture risk to women age 65 as calculated by FRAX* (Fracture Risk Assessment) tool or other validated scoring tool.

Men or women

  • Long term exposure to glucocorticoids (i.e. current or past exposure to glucocorticoids for more than 3 months),
  • Androgen deprivation,
    Or
  • Other conditions known to be associated with low bone mass.

Repeat Screening:

  • T-score** > -1.5, 15 years to next screening test
  • T-score -1.5 to -1.99, 5 years to next screening test
  • T-score ≤ -2.0, 1 year to next screening test
    Or
  • Use of medication associated with low bone mass or presence of a condition known to be associated with low bone mass.

Monitoring Treatment:

  • Once treatment for osteoporosis has begun, serial monitoring is not covered
  • Development of a fragility fracture alone is not a covered indication

* FRAX available at: http://www.shef.ac.uk/FRAX/

**T-Score refers to result of a DXA (dual-energy x-ray absorptiometry) scan compared to a reference population.

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed screening & monitoring tests for osteopenia/osteoporosis on November 21, 2014. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that the tests are a covered benefit with conditions. Complete information on this HTCC determination is available here: What we're working on | Washington State Health Care Authority.

Implementation of the Decision

A DXA scan may be used only for care of a condition accepted on the claim. All requests require prior authorization.