Blue Cross Blue Shield of Minnesota Medical Policy


Medical Policy:
Whole Body Dual X-Ray Absorptiometry (DXA) to Determine Body Composition
Effective Date:
July 1, 2019
Issued Date:
June 28, 2021
Last Revision Date:
June 2019
Annual Review:
June 2021

This policy version was replaced August 1, 2022. To find the newest version, go to, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Measurements of body composition have been used to study how lean body mass and body fat change during health and disease, and have provided a research tool to study the metabolic effects of aging, obesity, and various wasting conditions such as occurs with AIDS or post bariatric surgery. A variety of techniques have been researched, including anthropomorphic measures, bioelectrical impedance, and underwater weighing. All of these techniques assume 2 body compartments (fat mass and fat-free mass) and are based in part on assumptions regarding the distribution of different body compartments and their density. In addition, all of these techniques rely on formulas to convert the measured parameter into an estimate of body composition.

An additional method, whole body dual x-ray absorptiometry (also known as DXA or DEXA), uses low-dose x-rays of 2 different energy levels to measure 3 compartments - lean tissue mass, total and regional body fat, as well as bone density. During whole body DXA, the entire body is scanned by an x-ray beam to determine body composition. Originally developed as a tool for diagnosing osteoporosis, dual x-ray absorptiometry has emerged as a new research technique for body composition studies.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Whole body dual x-ray absorptiometry to determine body composition is considered EXPERIMENTAL/INVESTIGATIVE for all indications due to the lack of clinical evidence demonstrating its impact on improved health outcomes.


Denial Statements

No additional statements.


Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites. 

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.


CPT® codes copyright American Medical Association® 2022. All rights reserved.

CDT codes copyright American Dental Association® 2022. All rights reserved.