Medicare will soon nationally reimburse a new method for osteoporosis screening that offers a more complete assessment of bone quality and fracture risk than current methods that rely solely on bone mineral density (BMD) measurements.
Called biomechanical CT (BCT), the method measures bone strength as well as BMD to offer more comprehensive evaluation of fracture risk than BMD alone.
Starting October 5, 2026, BCT will be fully covered as a Bone Mass Measurement (CPT codes 055T-0558T) preventive services benefit for osteoporosis diagnostic screening for eligible Medicare beneficiaries, with retroactive coverage effective to January 1, 2024.
Tony Keaveny, PhD, distinguished professor emeritus of mechanical engineering and bioengineering at the University of California, Berkeley, who spearheaded development of the technology, said he hopes this national reimbursement development will now help “move the needle” for getting this test into clinical practice guidelines for osteoporosis, which are currently focused mostly on DEXA.
- Medicare covers BCT screening starting Oct 5, 2026; retroactive to Jan 1, 2024.
- BCT assesses bone strength + BMD; better fracture-risk stratification than BMD alone.
- Best use = opportunistic screening from existing CT scans; no extra imaging needed.
- BCT may complement DEXA; baseline DEXA still allowed for monitoring during therapy.
- Limitations: CT requirement, access, and scanner/software/protocol variability; DEXA remains first-line.
“By incorporating BCT into Medicare’s Bone Mass Measurement benefit, Medicare is recognizing BCT as a preventive screening option for osteoporosis,” he said, adding that this new coverage policy will also likely lead to broader adoption by commercial payers over time.
To date, BCT is clinically used only in select hospitals and by early adopters, mostly endocrinologists and spine surgeons, who learned about it from research conferences.
One caveat to the technology is that it requires a CT scan.
As such, Keaveny said that the technology is best suited for people with preexisting CT scans for other medical reasons. Older adults, many of whom have an existing CT scan, stand to benefit the most from the test. “For these patients, BCT can provide accurate osteoporosis assessment without requiring an additional imaging appointment, and DEXA confirmation is not needed,” he said.
He also emphasized that, as with other types of Bone Mass Measurement tests and when medically necessary, Medicare still permits patients diagnosed with osteoporosis via BCT to obtain a baseline DEXA examination for subsequent monitoring during drug treatment. “Therefore, using BCT for diagnosis does not preclude monitoring by DEXA when clinically indicated,” he said.
Keaveny, who founded O.N. Diagnostics in 2005, the company that developed and clinically validated BCT supported largely by the National Institutes of Health, said the evidence on its effectiveness as a screening tool is substantial with over 70 peer-reviewed studies. The method, called VirtuOst BCT, is indicated by the FDA to assess fracture risk, identify osteoporosis, and monitor therapy in the US, and is currently clinically available only through O.N. Diagnostics.
Rational and Evidence Behind BCT
The idea behind BCT grew out of research conducted at the University of California, San Francisco, and University of California, Berkeley, on basic bone biomechanics and finite element analysis of bones. The key motivation, according to Keaveny, was to address what many consider a longstanding crisis in osteoporosis care — undiagnosed and untreated fracture risk in too many high-risk people.
Their research showed them that bone strength along with BMD can identify more patients at high risk for fracture than BMD alone. Evidence from multiple fracture-outcome studies for hip and spine fractures, for example, showed fracture risk more strongly related to low bone strength than BMD alone. Keaveny underscored that fractures occur because bone strength is insufficient to withstand loading, yet BMD has historically been the sole measure to assess osteoporosis. Along with BMD, other factors that influence bone strength include bone size, bone geometry, the relative contributions of cortical and trabecular bone, the spatial distribution of the bone tissue, and the types of forces acting on the bone.
Based on this research, Keaveny and colleagues believed that two advances in osteoporosis screening were needed: provide a test that identifies patients with clinically significant bone fragility (and not just low BMD) and expand access to testing so that more high-risk patients actually get evaluated and treated.
The BCT test was born and over the past couple decades has been clinically tested and shown to be superior to DEXA alone. For example, a comparison of BCT and DEXA in over 100,000 patients in a Kaiser Permanente Southern California study showed bone strength by BCT predicted a future hip fracture independently of hip BMD T-score with improved sensitivity (and similar specificity) compared to DEXA for identifying patients who later had hip fractures.
Keaveny and colleagues at O.N. Diagnostics also developed the proprietary method for quantitatively assessing bone density in previously taken CT scans, which involves the use of a phantom-less calibration method using a patient’s own internal tissues as calibration references. The technique allows for accurate analysis of bone density and strength in most existing CT scans of hips and spines without the need for a calibration phantom during the scan.
Expanding BCT Screening Access
Now with national Medicare coverage as part of the Bone Mass Measurement preventive service benefit, Keaveny and colleagues are focusing on scaling up the use of BCT for osteoporosis screening. Keaveny emphasized that BCT provides physicians with familiar measurements of BMD and that measurements of bone strength are easy to interpret, so it could fit readily into current guidelines.
He cited one group, the International Society for Clinical Densitometry, that already recognizes low bone strength measured by BCT as a criterion for identifying patients who may be candidates for osteoporosis therapy.
He underscored that screening guidelines for BMD testing need to evolve toward a more inclusive model to incorporate multiple validated technologies, such as with colorectal cancer screening, which no longer relies on a single test. “I would hope that osteoporosis screening moves in a similar direction, where DEXA remains an important tool but is complemented by other validated and nationally covered technologies for BMD testing, such as BCT, that can help reach patients who might otherwise go untested,” he said.
Does BCT Add Value?
Daniel Bikle, MD, PhD, an endocrinologist at the San Francisco VA Medical Center in San Francisco, who has worked closely with Keaveny and his team in using BCT in clinical trials, said the data show the added value of BCT. For example, one study showed that application of BCT analysis to existing CT scans in older male veterans found a higher proportion of men with osteoporosis not previously diagnosed or treated. Another study found that BCT accurately predicted future fracture risk in men undergoing androgen therapy for metastatic prostate cancer.
He called BCT a “step up” from what is currently used. “I think it is useful especially to predict bone strength and fracture risk in patients with breast cancer and prostate cancer who have undergone CT scans to look for metastases,” he said, adding that bone strength is a “big deal” and identifying fracture risk is helpful to treating bone upfront.
He sees the main use of BCT as opportunistically taking advantage of preexisting CT scans and doubts it will be used in patients without previous scans.
John Schousboe, MD, a rheumatologist at the University of Minnesota, Minneapolis, who directed the Bone Densitometry Center for Park Nicollet Clinic in Minneapolis for 26 years, also thinks BCT only adds value for opportunistic osteoporosis screening in people with previous CT scans for other medical reasons and who have not had a previous BMD test.
“For people already screened for BMD for bone health, BCT doesn’t add enough value to make enough of a difference,” he said. “I’m fine using it for identifying folks who have not had a BMD who need to be treated or need further evaluation.”
He used the example of someone getting a CT scan to examine the pelvis. “You can’t help but include the hip in that scan,” he said. “So you can opportunistically apply BCT as a prescreen to decide if the person has osteoporosis and should be treated or further evaluated.”
JoAnn Pinkerton, MD, the Mamie A. Jessup Professor of Obstetrics and Gynecology and division director for Midlife Health in the University of Virginia Health System in Charlottesville, Virginia, who helped develop the American College of Obstetricians & Gynecologists guidance on osteoporosis prevention, screening, and diagnosis, thought that BCT should be included in osteoporosis screening guidelines as it becomes more common. However, she cited the lack of standardization of BCT and lack of access as limiting its formal incorporation into broad, standard guidelines.
“DEXA scans are standardized and can be compared to another done on the same machine, whereas BCT analysis may vary depending on the brand of CT scanner, software, and protocol used,” she said, adding that this makes it difficult to compare results between machines.
For women who meet the criteria for Medicare coverage, she thinks BCT may provide information on their fracture risk without the need for additional testing. Given that Medicare coverage is based on medical necessity, she said this could include women at risk for osteoporosis due to estrogen deficiency, women taking steroid medications, women diagnosed with primary hyperparathyroidism, or for those already on current osteoporosis treatment in whom monitoring is needed.
“However, Medicare is not going to cover two tests for the same diagnosis,” she said. “Thus, the standardized DEXA will still be recommended first line for the majority of patients.”
Keaveny reported holding equity in O.N. Diagnostics and serving as a consultant for Amgen and Bone Health Technologies. Bikle, Schousboe, and Pinkerton said that they have no relevant financial relationships to disclose.
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