CPT 77085, in plain terms, covers DXA bone density of the axial skeleton, such as spine and hips, including vertebral fracture assessment in the same session. CPT 77085 is referenced in 15 tracked payer policy changes from Sentara Health Plans, Excellus BlueCross BlueShield, and 9 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 77085 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 77085 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.
Capital Blue Cross has implemented new prior authorization requirements for specialty injectable medications and medical procedures. Key changes include PA requirements for new drug Itvisma (J3590), power wheelchair accessories (E0986), and radiofrequency ablation of thyroid tumors (60660, 60661).
Blue Cross Blue Shield of North Dakota updated multiple medical policies with new covered services, revised criteria, coding changes, and consent policies effective February 19, 2026. Key changes include new procedure codes for prostate treatments, bone density studies, and various other specialties, plus removal of experimental procedure codes.
Blue Cross and Blue Shield of Nebraska (BCBSNE) is updating six medical policies effective 2/15/2026, including new coverage criteria and billing codes for cardiac imaging (CTA with code 75580), bone density testing (code 77078), amniotic membrane products, bioengineered skin substitutes, respiratory oscillatory devices, and hypoglossal nerve stimulation for sleep apnea. Most updates require prior authorization and define specific medically necessary indications; procedures outside stated criteria are classified as investigational.
Blue Cross Blue Shield of Nebraska updated six medical policies effective February 15, 2026, adding new prior authorization requirements for CTA and bone density tests, expanding coverage criteria for amniotic membrane treatments and bioengineered skin substitutes, and updating respiratory device and sleep apnea surgery criteria.
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.
CMS's MLN Connects newsletter (issue dated 2026-11-05) revised several Medicare preventive services entries: medication-induced movement disorder screenings were added to alcohol misuse screening/counseling, the annual wellness visit, depression screening, and the initial preventive physical exam; ICD-10 code Q87.A was added to the bone mass measurement codes file effective October 1, 2026, with frequency-restriction exemptions noted for certain diagnoses billed with CPT 77080 or 77085; CPT 0421U was added to colorectal cancer screening effective June 8, 2026; CPT 90616 was added for flu shot administration effective August 5, 2026; and the GLP-1 Bridge Program for Medicare Part D patients was added under intensive behavioral therapy for obesity. Several of these effective dates precede the November 6, 2026 analysis date and should be treated as already effective, so the billing team should verify current applicability rather than treat them as future deadlines.
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 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.
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.
This is a reissue with no substantive changes to Independence Blue Cross Commercial policy 09.00.40d. The policy maintains its position that screening for vertebral fracture using DEXA/DXA (CPT 77085, 77086) is considered experimental/investigational and is NOT covered under commercial medical benefits. Billing teams should continue denying claims for vertebral fracture assessment via DEXA/DXA.
Independence Blue Cross reissued Policy 09.00.40d confirming that screening for vertebral fractures using DEXA/DXA remains non-covered as an experimental/investigational service. No substantive changes were made; this is a routine annual policy reaffirmation. CPT codes 77085 and 77086 continue to be non-billable under commercial plans.
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