Brief Description of Measure:
CMS249: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture:
Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period

Description of Issue:
The measure's current logic requires osteoporosis to start before the measurement period and continue into the measurement period, using CQL operator "overlaps before"; osteopenia is only required to start any time before the start of the measurement period and may or may not continue into the measurement period, using CQL operator "starts before start".
 
The measure developer proposes to align the osteoporosis timing with that applied to osteopenia as the two conditions are similar and the applied exclusion criteria should be reflect that. The description of the timing requirement in the header would also be rephrased to align with the logic performance. 
 
To bring the two exclusions into closer alignment, there is also an opportunity to align the logic structure (e.g., convert "Osteopenia before Measurement Period" into a Boolean return by adding "exists" to the definition).

Proposed Solution:
​Below are changes in the logic.

//Before
define "Has Osteoporosis Before Measurement Period":
  exists ["Diagnosis": "Osteoporosis"] OsteoporosisDiagnosis
    where OsteoporosisDiagnosis.prevalencePeriod overlaps before "Measurement Period"

define "Osteopenia Before Measurement Period":
  ["Diagnosis": "Osteopenia"] OsteopeniaDiagnosis
    where OsteopeniaDiagnosis.prevalencePeriod starts before start "Measurement Period"

//After
define "Has Osteoporosis Before Measurement Period":
  exists ["Diagnosis": "Osteoporosis"] OsteoporosisDiagnosis
    where OsteoporosisDiagnosis.prevalencePeriod starts before start of "Measurement Period"

define "Has Osteopenia Before Measurement Period":
  exists ["Diagnosis": "Osteopenia"] OsteopeniaDiagnosis
    where OsteopeniaDiagnosis.prevalencePeriod starts before start of "Measurement Period"

Below are changes in the header.

//Before
The following risk factors may occur at any time in the patient's history and must not start during the measurement period:

//After
The following risk factors may occur at any time in the patient's history prior to the start of the measurement period:

Rationale for Change:
The measure developer proposes to align the osteoporosis timing with timing of osteopenia to harmonize the measure logic for these similar conditions. Relaxing the timing requirement for osteoporosis would also increase the likelihood of excluding individuals with increased osteoporosis risk, which aligns with the measure intent.