Medicare Coverage for Osteoporosis

With the passage of the Affordable Care Act in 2010, Medicare expanded its coverage of preventive services. Many of those services became free to beneficiaries as long as their Medicare doctor accepted assignment, i.e., they agreed to the terms of Medicare's annual fee schedule.

Some of these screening tests are limited to people who are considered to be high risk for certain conditions. Unfortunately, when it comes to osteoporosis screening, Medicare may not be offering the same level of care to men that it offers to women. The problem is that men are more likely to suffer from complications.

Osteoporosis and Its Complications

Osteoporosis is a medical condition characterized by architectural weakening in the bones and decreased bone mass. These changes make the bones more fragile and increase the risk of fractures, especially at the spine, hip, and wrist.

The International Osteoporosis Foundation estimates that someone has an osteoporotic fracture every three seconds, affecting a third of women and a fifth of men over their lifetimes. Debility from the condition can be significant due to decreased mobility, loss of independence, and chronic pain.

Notably, people who have hip fractures are at increased risk of dying. A 2017 study of 122,000 people found that for those who had a hip fracture, their mortality rate doubled for up to eight years afterwards.

Risk Factors for Osteoporosis

When you think of osteoporosis, you likely think of women. It is true that postmenopausal women are at highest risk for the condition. Once their bodies no longer produce premenopausal levels of estrogen, the protective benefits of the hormone on their bones go away.

Adult men, unless they have hypogonadism, generally have steady hormone levels (testosterone) throughout their lives. However, decreases in the sex hormones are not the only risk factors for osteoporosis.

You must also consider factors like advanced age, disorders that affect calcium metabolism (e.g., hyperparathyroidism), a family history for osteoporosis, excessive alcohol use, long-term use of certain medications (e.g., steroids), low body weight, low calcium intake, malabsorptive conditions (e.g., celiac disease), race (higher risk in White adults than in Black, Latinx, or Asian adults), a sedentary lifestyle, smoking, and vitamin D deficiency.

Qualifying for Medicare Osteoporosis Screening

Medicare covers osteoporosis screening for people who have one or more of the following:

• Anyone currently receiving treatment for osteoporosis
• Estrogen deficiency or menopause
• Prednisone or steroid-type drug use
• Primary hyperparathyroidism
• X-rays suggestive for osteopenia or osteoporosis
• X-ray suggestive for vertebral fracture

As you can see, screening is tailored towards women or people who already have confirmed osteoporosis or X-ray suspicion for the diagnosis. It is easy to see that men and many people who have modifiable risk factors, like smoking and alcohol use, are excluded.

Osteoporosis Screening for Men

Women are more likely to develop osteoporosis, but that does not mean that men do not get the condition. One in five people with osteoporosis are men, according to the International Osteoporosis Foundation. When looking at data from the American Cancer Society, that represents more men than will get prostate cancer (1 in 9) in their lifetimes.

About two million men in the United States have osteoporosis, and they tend to have higher mortality rates than women. Studies show that men have almost twice the mortality rate after a hip fracture.

Unfortunately, Medicare's osteoporosis screening guidelines are not all-inclusive and men are often left out. Simply put, it is considerably harder for a man to get a bone density study or DEXA scan.

Men are less likely to be screened regardless of having known risk factors for osteoporosis. The underweight senior man who cannot afford dentures and develops vitamin deficiencies because he cannot eat a regular diet? The man with prostate cancer who is on hormone therapies that could weaken his bones? These men have verifiable medical conditions that often place them at increased risk of osteoporosis but traditional Medicare does not cover them.

If a healthcare provider has concerns, the test can still be ordered though it may (or may not) be covered as a free preventive service. An appeal to Medicare could show the test is medically necessary.

In that case, the beneficiary would pay 20% of the test's costs, the usual Medicare Part B coinsurance. Otherwise, the beneficiary will need to pay the full cost out of pocket. Medicare Advantage plans work differently than Original Medicare and could offer expanded screening options.

Treatment Disparities for Men and Women

Not only are men less likely to be screened for osteoporosis, they are less likely to be treated once a diagnosis is made. A 2012 study of over 17,000 men found that less than 10% of men received osteoporosis treatment, even after a fracture. They were more likely to receive treatment if they had a spinal fracture, were taking steroids or antidepressants, or were seeing a primary care physician.

There are many calcium and vitamin D supplements available over the counter but people with osteoporosis may need prescription medications. Again, men may be at a disadvantage when compared to their female counterparts.

Medicare Part D covers most prescription medications, depending on the plan’s formulary. However, Part B does pay for some injectable osteoporosis medications but only for women.

Specifically, you must be a woman with a postmenopausal osteoporotic fracture, you are unable to inject the medication yourself, and you do not have family members or caregivers who will help you do it. Once your healthcare provider certifies all this to be true, Medicare will pay 20% the cost of your medication. Otherwise, you will need to turn to your Part D benefits, if you have them.

A Word From Verywell

Medicare guidelines for osteoporosis screening are limited. A bone density scan may be pursued every 24 months for menopausal women, people with hyperparathyroidism, people on steroid medications, or people with X-ray findings that are suggestive for the condition. Men, unfortunately, will find it harder to get covered. Medicare Part B will also not pay for injectable osteoporosis medications even though they pay for women.