Medicare Coverage Of Osteoporosis Medications
Many medications available today can slow the rate of bone loss and, in some cases, even rebuild bone strength.
Osteoporosis medications include oral drugs such as tablets and liquids. You may also be prescribed injectable drugs that you receive at your doctors office or administer to yourself at home.
According to the Mayo Clinic, the most widely prescribed osteoporosis medications for both men and women are bisphosphonates.
There are several types of bisphosphonates, including the following:
- Pills such as alendronate , ibandronate or risedronate that are taken daily, weekly or monthly
- Injections of ibandronate that are given once every three months
- Intravenous infusions of zoledronic acid that are given once a year
Medicare Part D plans and Medicare Advantage plans with prescription drug coverage will cover a portion of the cost of most bisphosphonates.
How much you pay out-of-pocket for your prescription depends on your plans formulary, or the list of drugs covered by your plan either in part or in full. Brand-name drugs and specialty drugs will cost more than generic drugs.
Who Should Undergo A Bone Density Test
Postmenopausal women, men ages 70 and older, or those who recently suffered from a broken bone are advised to take a bone density test. Women are at high risk for osteoporosis. Bone loss is women is fastest during the first few years after menopause and continues into old age.
Men, on the other hand, start to lose bone mass at a faster rate at the age of 65.
Additional factors to consider for people who are at high risk for losing bone mass is a small body frame and long-term use of corticosteroids.
The National Osteoporosis Foundation recommends that people taking osteoporosis medications undergo a bone density test every one to two years. People who are starting a new osteoporosis medication are advised to repeat a bone density test after a year.
Medicare Part B covers bone density tests every 24 months if a person is determined by a health provider to be at risk for osteoporosis. Medicare considers you to be at high risk if:
- you are a woman found to be estrogen-deficient
- x-ray shows that you are suffering from vertebral abnormalities
- you are receiving daily steroid-type treatments, corticosteroids, or prednisone for more than three months
- you have been diagnosed with hyperparathyroidism
- you are receiving osteoporosis drug therapy
All these tests are covered if the doctor accepts the assignment. However, a doctor may recommend additional tests more than Medicare covers. In such cases, you may be asked to pay for some or all the costs.
Osteoporosis And Its Complications
Osteoporosis is a medical condition characterized by architectural weakening in the bones and decreased bone mass. These changes make the bones more fragile and increase the risk of fractures, especially at the spine, hip, and wrist.
The International Osteoporosis Foundation estimates that someone has an osteoporotic fracture every three seconds, affecting a third of women and a fifth of men over their lifetimes. Debility from the condition can be significant due to decreased mobility, loss of independence, and chronic pain.
Notably, people who have hip fractures are at increased risk of dying. A 2017 study of 122,000 people found that for those who had a hip fracture, their mortality rate doubled for up to eight years afterwards.
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Risk Factors For Osteoporosis
When you think of osteoporosis, you likely think of women. It is true that postmenopausal women are at highest risk for the condition. Once their bodies no longer produce premenopausal levels of estrogen, the protective benefits of the hormone on their bones go away.
Adult men, unless they have hypogonadism, generally have steady hormone levels throughout their lives. However, decreases in the sex hormones are not the only risk factors for osteoporosis.
You must also consider factors like advanced age, disorders that affect calcium metabolism , a family history for osteoporosis, excessive alcohol use, long-term use of certain medications , low body weight, low calcium intake, malabsorptive conditions , race , a sedentary lifestyle, smoking, and vitamin D deficiency.
Does Medicare Cover Bone Density Testing
Fortunately, Medicare feels that bone health is essential and can help you get excellent bone care, whether it be testing or treatment. There are about 10 million people in the United States alone with Osteoporosis and almost 34 million more with low bone mass.
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How Is Bone Density Testing Done
Bone density testing is typically done in a clinical setting such as a hospital or an outpatient facility. After putting on a loose gown, youll be asked to lie on a padded platform. A suspended mechanical arm then passes over parts of your body, taking images of your skeleton.
The test generally takes between 10 and 30 minutes and exposes you to less radiation than a chest X-ray. A radiologist then reads the images and provides results, which include two components: T-score and Z-score.
How To Get Help Covering The Cost Of Bone Density Testing Under Medicare
Supplemental plans fill in the gaps by covering the 20% you would otherwise pay under Part B. By relieving you of this cost, you can worry less about bills and more about recovery. The best part about a supplement is that when Medicare approves a service, the supplement must authorize the service as well. Knowing this gives many beneficiaries peace of mind.
If you think youd benefit from supplemental coverage, give us a call. Well take the time to provide you with the information to compare as well as select the right plan. Also, if you have a plan and want to find a lower premium, contact us today! If you dont feel like calling in now, compare rates online!
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Medicare And Bone Density Tests
Bone density tests also referred to as bone mass measurements is a diagnostic test for osteoporosis. It is used to measure bone density and determine the risk of breaking a bone.
The test is usually performed using a dual x-ray absorptiometry machine that measures the amount of bone in the spine, hip, and other bones.
The test results will help a healthcare provider make recommendations to protect and prevent further bone loss.
A bone density test is used to determine if a person has low bone density. People with low bone density have a higher risk of breaking a bone. Bone mass measurements can help a healthcare provider determine:
- if a person is suffering from low bone density
- the best treatment for improving bone density
- if current therapies are effective in addressing bone loss
- if the condition is getting worse
- a persons risk for breaking a bone in the future
What Is Bone Density Testing
Bone density testing, which is sometimes referred to as bone densitometry or DEXA, is a type of imaging that measures how many bone minerals, including grams of calcium, are in a section of bone . A higher concentration of mineral content means denser, stronger bones, which are generally less likely to break.
Bone density testing is often used to confirm whether an individual has osteoporosis, which is indicated by fragile bones that may break easily. The test may also be helpful in determining an individuals risk of fractures and is often used to monitor a person undergoing treatment for osteoporosis.
This test may be ordered as part of a routine screening for an aging individual, or it may be recommended if youve fractured a bone, had a drop in hormone levels or experienced a significant loss of height.
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The Cost Of Screening Dexa Scans
The average cost of a Dexa scan is around $150 to $250. The total cost of a DEXA scan also includes the doctors consultation.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Types Of Bone Density Tests
Two types of machines can measure bone density. Central machines test it in the hip, spine, and total body. Doctors can use them to do different types of bone density tests:
- DXA measures the spine, hip, or total body. Doctors consider this test the most useful and reliable for checking bone density.
- QCT usually measures the spine, but it can test other sites, too. This test is not often used because it is costly and delivers a lot of radiation.
Peripheral machines check the finger, wrist, kneecap, shinbone, and heel. These machines are a good option when DXA scans arenât available. But DXA scans are still the best choice for screening. Peripheral screening tests include:
- pDXA measures the wrist or heel.
- QUS uses sound waves to measure density, usually at the heel.
- pQCT measures the wrist.
Once you get your test results, you and your doctor can decide what to do next.
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Qualifying For Medicare Osteoporosis Screening
Medicare covers osteoporosis screening for people who have one or more of the following:
- Anyone currently receiving treatment for osteoporosis
- Estrogen deficiency or menopause
- X-rays suggestive for osteopenia or osteoporosis
- X-ray suggestive for vertebral fracture
As you can see, screening is tailored towards women or people who already have confirmed osteoporosis or X-ray suspicion for the diagnosis. It is easy to see that men and many people who have modifiable risk factors, like smoking and alcohol use, are excluded.
Treatment Disparities For Men And Women
Not only are men less likely to be screened for osteoporosis, they are less likely to be treated once a diagnosis is made. A 2012 study of over 17,000 men found that less than 10% of men received osteoporosis treatment, even after a fracture. They were more likely to receive treatment if they had a spinal fracture, were taking steroids or antidepressants, or were seeing a primary care physician.
There are many calcium and vitamin D supplements available over the counter but people with osteoporosis may need prescription medications. Again, men may be at a disadvantage when compared to their female counterparts.
Medicare Part D covers most prescription medications, depending on the planâs formulary. However, Part B does pay for some injectable osteoporosis medications but only for women.
Specifically, you must be a woman with a postmenopausal osteoporotic fracture, you are unable to inject the medication yourself, and you do not have family members or caregivers who will help you do it. Once your healthcare provider certifies all this to be true, Medicare will pay 20% the cost of your medication. Otherwise, you will need to turn to your Part D benefits, if you have them.
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What Is A Bone Density Test
A bone density test is an imaging study that uses a small amount of ionized radiation and an X-ray machine to measure the strength of your bones.
Also called dual energy X-ray absorptiometry , this test allows your doctor to measure the amount of minerals like calcium in your bones.
This test can be used to find mineral deficiencies that may be caused by:
- age or certain diseases
- increased air space
- other problems in your bones
A number of hereditary and lifestyle traits can contribute to bone loss and weakness. Your doctor will assess your risk based on several factors, including:
- low body weight or chronic malnutrition
- rheumatoid arthritis
- chronic kidney disease
How Much Will Medicare Pay
People enrolled in Original Medicare and satisfy all the conditions set for coverage are entitled to 100% coverage of the Medicare-approve amount from a participating provider. Medicare pays for all the costs of the bone density test if performed by a participating provider.
These providers will accept the assignment and only charges Medicare-approved amounts as full payment. Bone density tests conducted by a non-participating provider should be prepared to make payments. It is because bone density tests by non-participating providers may cost more than the maximum amount Medicare covers.
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Will Medicare Cover A Bone Density Test
Bone density is usually measured with an imaging test similar to an X-ray. This scan will give your doctor information about the health and strength of your bones.
Several types of bone density tests exist. The preferred test is now the bone density mineral test. Medicare removed other similar tests when it updated the current benefit guidelines in 2007.
Because certain conditions put you at a higher risk for bone problems and related injuries, Medicare covers bone density testing once every 24 months.
You may qualify for more frequent testing if you have any of the following conditions, which could lead to decreased bone density:
The basic conditions for coverage are:
- Your doctor has ordered the scan as a medically necessary test.
- Its been 23 months since your last bone density scan or you have a condition that needs more frequent testing.
- The facility where the scan is done accepts Medicare.
To check whether a medical facility participates in Medicare, click here.
Does Insurance Cover It
Most health insurers will pay for the test if you have one or more things that raise the chances you have osteoporosis, such as:
- A fracture
- Youâve been through menopause
- Youâre not taking estrogen at menopause
- You take medications that cause bone thinning
Medicare covers bone density testing for specific types of people ages 65 and older:
- Women whose doctors say theyâre low in estrogen and at risk for osteoporosis
- People whose X-rays show they may have osteoporosis, osteopenia, or spine fractures
- People who take steroid medicines or plan to start
- People with primary hyperparathyroidism
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Who Should Get A Bone Density Test
The National Institutes of Health recommends that people with a higher risk for osteoporosis get bone density tests to screen for bone mineral loss this includes all women 65 and older, and men 65 and over if theyre considered at high risk for fractures. Certain prescription drugs are known to contribute to bone loss, so you might want to ask your doctor about the medications you take.
In addition, you may want to talk to your doctor about getting the bone density test if you have any of the risk factors associated with osteoporosis, which include :
- You have rheumatoid arthritis, chronic kidney disease, or an eating disorder.
- Youre a woman who had an early menopause .
- You get very little exercise.
- Youve experienced height loss because of compression fractures in your spine.
- You smoke.
- Youre a frequent and heavy alcohol drinker.
- You have a strong family history of osteoporosis.
Your doctor can recommend how often to get a bone density test based on your current status and risk factors.
What Icd 10 Codes Cover A Dexa Scan
Encounter for screening for osteoporosisZ13. 820 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
Furthermore, does insurance cover DEXA scan? While the DEXA test is painless, the cost may not be not every insurance plan will cover all types of diagnostic scanning tests. Based on your personal risk factors and concern about osteoporosis, you and your doctor can decide if a DEXA bone density scan is right for you.
Furthermore, what is the CPT code for a DEXA scan?
CPT code for this procedure for one or more sites is 77080. CPT code for vertebral fracture assessment is 77082. A DEXA scan is currently the most widely-used test in measuring bone mineral density.
What is diagnosis code z13 820?
Z13. 820 is a billable ICD code used to specify a diagnosis of encounter for screening for osteoporosis. A ‘billable code‘ is detailed enough to be used to specify a medical diagnosis.
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How Much Does Medicare Cover For Bone Density Testing
If bone density testing is done on an outpatient basis, it may be fully covered under Medicare Part B. To ensure that youll incur no out-of-pocket costs, the test must be deemed medically necessary by the prescribing physician and performed at a Medicare-approved facility. At least 23 months must have passed since your last bone density test, unless youre approved for more frequent testing. If you qualify for more frequent testing, your physician must provide proof of medical necessity.
Bone density testing may also be done as part of an inpatient stay at a hospital or skilled nursing facility. In these cases, testing is reimbursable under Part A, Medicares hospitalization component. Once the Part A deductible has been met, the test is fully covered as long as its performed during your first 60 days at the facility. If its performed after 60 days, you may be responsible for paying a coinsurance.
Medicare Advantage beneficiaries are guaranteed to receive, at minimum, the same coverage as that provided under Original Medicare. However, certain plans may provide additional coverage for bone density testing. For your plans specific coverage terms, contact your Medicare advisor or a plan administrator.