Dexa Scan denied for failing step therapy by Medicare?

Medicare's specific coverage criteria for dexa scan are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Medicare Denies a DEXA Scan Under Step Therapy

Step-therapy denials are uncommon for diagnostic imaging services like DEXA scans because step therapy is typically applied to drug prescriptions. When this denial appears on a DEXA claim, it usually means either (1) the patient is in a Medicare Advantage plan that has applied a step-edit requiring a different or less resource-intensive assessment to be tried and documented before covering a DEXA scan, or (2) the denial was miscoded and a different denial type was intended. In either case, the denial is challengeable.

## Why This Denial Is Appealable

If a Medicare Advantage plan is requiring a lesser diagnostic test as a prerequisite to DEXA coverage, the appeal should establish why that lesser test does not adequately answer the clinical question. Medicare Advantage plans are bound by CMS rules that prohibit step-therapy requirements that are clinically inappropriate, and a clinically unjustified step-edit on a diagnostic imaging service is a strong appeal candidate. If the denial is a miscoding, a simple correction request may resolve it.

## Federal Appeal Framework

• Medicare Advantage: internal appeal within 60 days of the denial notice (or 72 hours for expedited pre-service) → ACA §2719 external review by a CMS-contracted Independent Review Organization if internal appeal fails.
• Traditional Medicare Part B: step-therapy denials on imaging claims are unusual; if encountered, file a Redetermination within 120 days.
• Expedited appeal is available when standard timing would jeopardize the patient's health or ability to regain maximum function.
• The external review window is generally within four months of exhausting internal remedies.

## Concrete Appeal Steps

1. Request the plan's written step-therapy or coverage policy for bone density studies and identify the specific prerequisite step required. 2. Determine whether the prerequisite step has already been completed; if so, submit the documentation proving completion. 3. If the prerequisite was not completed because the ordering provider determined it was clinically inadequate, obtain a letter from the ordering provider explaining the clinical reasoning. 4. Research whether CMS has issued guidance limiting step-therapy use for diagnostic imaging in Medicare Advantage (check cms.gov for current guidance). 5. Submit the appeal with the clinical rationale, the provider letter, and any CMS guidance supporting the argument that the step requirement is impermissible or inappropriate.

## Documentation Checklist

• Denial notice with the specific step-therapy requirement cited
• Plan's written policy for bone density measurement coverage
• Ordering provider's letter explaining why a DEXA scan (rather than a lesser alternative) is the clinically appropriate first-line study
• Any prior diagnostic workup results that are relevant
• Clinical notes documenting the indication and clinical urgency
• CMS guidance on step-therapy limitations in Medicare Advantage (if applicable)

## Criteria-Mapping Structure

Address the step-therapy requirement directly: either document that the required prerequisite step was completed (with dates and outcomes), or explain — supported by the ordering provider's clinical judgment and any applicable professional society guidance — why bypassing that step is medically necessary. Map each plan requirement to a specific chart fact or clinical rationale. Attach the relevant plan policy text so the reviewer can verify the mapping without hunting for the source.