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Did you have a DEXA scan before the 2 year mark covered by Medicare?

Posted by chiefsmom @chiefsmom, Sep 27 10:46am

I am nearing the end of my Evenity regimen - my last shots will be in November. I would like to have a DEXA scan to see my bone density results but my next 2-year DEXA is not due until 6/17/2027. Research on the Medicare site indicates a DEXA before 2 years would be covered if considered medically necessary. I am hoping my Rheumatologist will code it so it is considered necessary due to osteroporosis and my scoliosis which she consideres is advanced due to the degree of my S curve. Has anyone had a DEXA covered before 2 years or did you have to pay for it out of pocket. I live in Pennsylvania.

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dbb | @dbb | Oct 1 10:09am
In reply to @briarrose "@dbb Good advice, dbb. I called Medicare and was informed...yes, Medicare will pay for a DEXA..." + (show)
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@dbb Good advice, dbb.
I called Medicare and was informed...yes, Medicare will pay for a DEXA scan before your 2 year mark IF your physician orders it/documents her/his reason "why" i.e. their rational for ordering it ahead of schedule.
For less than $200 I would also do self pay.
I am going to run this by my PCP first - see what she thinks. Then my oncologist.
If both are a "no, it's too early" I will look into self pay/billing department at my medical facility.
Best wishes to all.

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@briarrose
I have been told by my doctors that Medicare usually never allows even with doctor's note, but still try because of your scoliosis. Everyone on Evinity should definitely have a DEXA after 12 months. Good luck!

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gently | @gently | Oct 1 12:11pm

briarrose, I keep reading endocrinologists saying confidently that bone changes don't show up on dxa for two to three years. While this might be true for older bisphosphonates, it isn't true for Evenity, Tymlos or Forteo. It certainly isn't true for the year after Evenity or even six months after Prolia.
I hope your PCP or oncologist will agree to write for the scan.
Thanks for the well wishes.

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prarysky | @prarysky | Oct 1 3:10pm
In reply to @gently "prarysky, it's a little weirder than that. You can't order by just the code, you need..." + (show)
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prarysky, it's a little weirder than that. You can't order by just the code, you need the descriptor. I think it is just a little cataloging error.

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@gently More thanks for filling in the details on ordering this particular test. You'd think they would fix his glitch. 🙁

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loriesco | @loriesco | Oct 1 3:41pm

@chiefsmom @dbb yes, mine have all been covered. It is not a matter of "coding" it needs a "prior auth." meaning the doctor needs to tell your insurance company WHY you need it between the 2 years. Mine have been requested because of the deterioration of the bones or because of possible surgery where bone integrity needs a current reading or because of my degenerative bone condition. dbb yes, mine have all been covered every year. It is not a matter of "coding" it properly it needs the doctor to tell your insurance company WHY you need it between the 2 years when the insurer rejects the request. I've had them every year for 30 years, either because of the deterioration of the bones or because of possible surgery where bone integrity needs a current reading or to monitor a medicine to see if it is working or because I have had DEXA scanned bones were removed and they have to use other new bones to scan for a baseline, or because I changed scanning machines and it was necessary to have a current status (ie, going to a "TBS" type machine). With compromised bones such as I have and my history, it may be crucial to monitor changes once a year compared to every two years. Definitely, it seems needed to gauge the changes of the bone medicine to determine if the medicine is working or not. 😉

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