Andrew Laster, MD, FACR, CCD
Public Policy Committee Chair
The indications for vertebral fracture assessment (VFA) now appear in the Official Positions of the ISCD. These indications originated with the ISCD Position Development Conference (PDC) in Vancouver in July of this year and represent the culmination of a rigorous process involving recommendations from the VFA Task Force, analysis by the PDC panel of experts (see link for members), public comment and final approval by the ISCD Board of Directors. They are as follows:
“Consider VFA when the results may influence clinical management.
“When BMD measurement is indicated, performance of VFA should be considered in clinical situations that may be associated with vertebral fractures. Examples include:
- Documented height loss of greater than 2 cm (0.75 in) or historical height loss greater than 4 cm (1.5 in) since young adult.
- History of fracture after age 50.
- Commitment to long-term oral or parenteral glucocorticoid therapy.
- History and/or findings suggestive of vertebral fracture not documented by prior radiologic study.
The Blue Cross and Blue Shield Association’s Medical Advisory Panel (MAP) met on 10/28/2005 and reviewed recommendations from their Technology Evaluation Center (TEC). In October of 2004 the same group had recommended that the 41 independent Blues not cover VFA. Although the BCBS TEC affirmed that VFA was an appropriate technology to identify vertebral fractures, they felt that scientific data was lacking that knowledge of vertebral fracture status altered clinical management of patients beyond awareness of BMD and “clinical risk factors”. The ISCD vigorously contested that evaluation and requested a subsequent review.
In two letters to BCBS the ISCD reviewed the 3 clinical trials of FDA approved drugs for osteoporosis which have demonstrated that knowledge of vertebral fracture status in patients with osteopenia (T-scores of better than -2.5 but lower than -1.0) significantly reduced the risk of subsequent vertebral fracture compared to those who did not have prevalent vertebral fractures. This approach, which incorporates fracture risk assessment with BMD to identify those at high risk for future fracture where treatment should be focused, mirrors the recommendations from the WHO and the ISCD Fracture Risk Reporting Task Force. Additional studies using cost benefit analysis have demonstrated that use of an antiresorptive in post-menopausal women with osteopenia is cost effective when vertebral fractures are present but not cost effective in their absence.
The ISCD requested and received strong letters of support for use of VFA in clinical management of patients from AACE, ACR (American College of Rheumatology), ASBMR and the NOF. When the full report of the second BCBS TEC denial is published within the next month, these 5 groups plan on collaborating in efforts to ensure that VFA coverage is achieved for individuals who are in BC BS plans.
To view copies of the two letters ISCD sent to BCBS visit the Public Policy Issues page. These letters review the scientific literature that supports the use of VFA and knowledge of vertebral fracture status in the management of patients with osteoporosis. The body of these letters may be copied and used to provide scientific support for VFA coverage if you are encountering denials from other insurers. Please contact your ISCD Public Policy Regional Representative if you have additional questions regarding VFA coverage.
Last modified: December 17, 2012