CPT 76977, in plain terms, covers Ultrasound measurement of bone density at a peripheral site such as the heel, with interpretation. CPT 76977 is referenced in 12 tracked payer policy changes from Sentara Health Plans, Excellus BlueCross BlueShield, and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 76977 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 76977 on AAPC
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Effective August 20, 2026, VFA with DEXA and TBS was removed from the list of investigational screening procedures, and DEXA can be completed with or without VFA or TBS. BMD testing is considered medically necessary when one of the listed methods is used, including DEXA, and one of the listed indications is met. Follow-up BMD testing is considered medically appropriate every two years, when at least 23 months have passed since the month of the last test, and testing every three years is recommended after starting bisphosphonate therapy.
Under this notice, administrative changes are effective on the date of the notice, material changes are effective 90 days from the date of the notice, and new prior authorizations are effective 30 days from the date of the notice, unless otherwise specified. Effective May 1, 2026, the maximum frequency per day (MFD) policy requires allowable units up to the MFD on one claim line and any additional units on a separate claim line, and new reimbursement policies cover related services and supplies (RP-202603) and replacement codes for CMS status indicator I (RP-202604). Effective with dates of service on or after June 1, 2026, non-clinical disputes and corrected claims must be submitted within 180 days from the date of the original claim determination, and these timelines replace the previous requirements. CPT 43889 is added to the bariatric surgery policy and requires prior authorization effective June 1, 2026. The notice also revises a number of medical policies, including removing the frequency limitation and prior authorization requirement for certain bone mineral density codes.
Bone density measurements are covered once per lifetime for general osteoporosis screening for women beginning at age 65 under the Healthy You! Wellness benefit, and screening is limited to the hips or spine using DEXA. An initial hip or spine measurement may be considered medically necessary for women age 65 and older, men age 70 and older, and others at risk of osteoporosis, and repeat measurements may be considered not more often than every 5 years for at-risk individuals who previously tested normal. The 10/01/2026 update added ICD-10 codes K74.0A, K76.83, Z68.18 and Z68.19, and Z68.1 was deleted as of 09/30/2026.
Capital Blue Cross's quality information bulletin describes four HEDIS quality measures for professional and facility providers: Breast Cancer Screening (BCS), Follow-up After Emergency Department Visit for Patients with Multiple High-Risk Chronic Conditions (FMC), Osteoporosis Management in Women Who Had a Fracture (OMW), and Plan All-Cause Readmission (PCR). Providers should routinely recommend and ensure mammography for patients ages 40 to 74, and women ages 67 to 85 who have had a fracture should receive a bone mineral density test or a prescription for an osteoporosis drug within 180 days after the fracture. Members 18 and older with multiple high-risk chronic conditions should have a follow-up service within 7 days of an emergency department visit, and supplemental data for these measures can be submitted through Theon.
Aetna considers measurements of bone turnover markers for evaluating fracture risk experimental, investigational, or unproven, including bone sialoprotein, cathepsin K, osteocalcin, osteoprotegerin, P1NP, RANKL, sclerostin, and CTX-1 and NTX-1 telopeptides. Aetna also considers plasma homocysteine for evaluating fracture risk, plasma leptin for osteoporosis screening, and serum or urinary collagen crosslinks or other bone remodeling markers for the screening, diagnosis, or management of osteoporosis experimental, investigational, or unproven. Measurement of bone-specific alkaline phosphatase as a diagnostic marker for children and adolescents with secondary osteoporosis, bone turnover markers for persons receiving serotonergic anti-depressants, and collagen crosslinks for bisphosphonate-induced jaw osteonecrosis, chronic kidney disease, or osteogenesis imperfecta are also experimental, investigational, or unproven.
Aetna considers bone mass measurement medically necessary when a member meets one of the listed criteria, such as long-term glucocorticoid therapy of 5 mg prednisone or more per day for more than 3 months, long-term anticonvulsant therapy, long-term aromatase inhibitor therapy, or non-traumatic (fragility) fractures. Repeat bone mass measurements are usually not indicated more frequently than once every 2 years, except in the circumstances the policy lists. Bone mass measurement by dual photon absorptiometry, dual X-ray and laser, single photon absorptiometry, pulse-echo ultrasound, cone beam CT, deep learning-based quantitative CT, finite element analysis, skin autofluorescence for AGEs, radiofrequency echographic multi spectrometry and urinary phthalate testing is considered experimental, investigational or unproven.
Aetna's Clinical Policy Bulletin 0642 considers surgery for neuralgia inducing cavitational osteonecrosis (NICO) related diagnoses experimental, investigational or unproven, including scraping of infected cavities and removal of root-canal-treated teeth. Other NICO therapies are also listed as experimental, investigational or unproven, namely rinsing the cavity with colloidal silver, chelation therapy, intravenous vitamin C and bone graft replacement. Devices that image the jawbones to diagnose NICO or NICO-type conditions are experimental, investigational or unproven because there is no adequate scientific evidence to support their clinical value, and the policy states that current evidence is insufficient to support NICO as a distinct, validated clinical entity.
Aetna considers these services medically necessary for members with anorexia nervosa or bulimia nervosa: medical evaluation with history and physical examination, psychiatric or psychological consultation and testing, blood count and serum chemistry, albumin and prealbumin, liver function tests, electrocardiography, urinalysis, thyroid function testing (TSH), bone density measurement for evaluation of anorexic members, and LH, FSH and estradiol for women with amenorrhea or oligomenorrhea. Treatment considered medically necessary includes nutritional counseling, psychotherapy (such as cognitive behavioral therapy, dialectical behavior therapy, family-based, interpersonal and psychodynamic psychotherapy), and enteral nutrition as a last resort for the treatment of anorexia nervosa. Self-administered pharmacotherapies are managed under the pharmacy benefit. The policy lists CPT and HCPCS codes covered if selection criteria are met, and codes not covered for the indications listed. Aetna considers a long list of services experimental, investigational or unproven for anorexia nervosa, bulimia nervosa and binge-eating disorder, including brain imaging, EEG, routine screening of asymptomatic adolescents and adults for eating disorders, acupuncture, deep brain stimulation, electroconvulsive therapy, repetitive transcranial magnetic stimulation, cannabinoids, oxytocin and ghrelin agonists.
Aetna considers measurement of bone turnover markers for evaluating fracture risk experimental, investigational, or unproven because their clinical value for this indication has not been established. The markers listed include bone sialoprotein, cathepsin K, osteocalcin, P1NP, CTX, sclerostin, osteoprotegerin, and RANKL. Aetna also considers experimental, investigational, or unproven the measurement of biochemical markers for diagnosis and monitoring of aseptic loosening or osteolysis in total joint arthroplasty, for osteoporosis screening, diagnosis, or management, plasma homocysteine for fracture risk, plasma leptin for osteoporosis screening, and serum microRNAs.
Capital Blue Cross sets quality measure requirements for professional and facility providers covering Breast Cancer Screening, Cervical Cancer Screening, depression screening, Follow-Up After Emergency Department Visit for Patients with Multiple High-Risk Chronic Conditions, and Osteoporosis Management in Women Who Had a Fracture. Mammography is recommended for patients ages 40 to 74, and cervical cancer screening applies to members ages 21 to 64 with cervical cytology within the last 3 years, or for ages 30 to 64 with hrHPV testing or cytology/hrHPV cotesting within the last 5 years, while depression screening is required once per measurement period for patients age 12 and older. Follow-up within 7 days of an emergency department visit (8 total days, including the day of the visit) is encouraged for members 18 and older with multiple high-risk chronic conditions, and women ages 67 to 85 who had a fracture should receive a bone mineral density test or a prescription for an osteoporosis drug within 180 days after the fracture.
BCBSRI has updated their HEDIS quality measure guidance for osteoporosis management in women who had fractures (OMW). This affects Medicare Advantage members ages 67-85 who had fractures, requiring bone mineral density tests or osteoporosis medication prescriptions within 6 months of fracture to close care gaps.
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