This General Policy section provides an overview of the basic criteria for which neck imaging may be medically necessary. Details regarding specific conditions or clinical presentations and the associated criteria for which imaging is medically necessary are described in subsequent sections.

† Advanced imaging of the neck covers the following areas:

® Skull base (thus a separate CPT^® code for head imaging in order to visualize the skull base is not necessary).
® Nasopharynx
® Upper oral cavity to the head of the clavicle
® Parotid glands and the supraclavicular region

† CT Neck

® CT Neck is usually obtained with contrast only (CPT^® 70491).
¡ Little significant information is added by performing a CT Neck without and with contrast (CPT^® 70492), and there is the risk of added radiation exposure, especially to the thyroid.
¡ CT Neck without contrast (CPT^® 70490) can be difficult to interpret due to difficulty identifying the blood vessels
¡ Exception: Contrast is not generally used when evaluating the trachea with CT. Evaluate salivary duct stones in the appropriate clinical circumstance where intravenous contrast may obscure high attenuation stones
¡ Contrast enhanced CT is helpful in the assessment of cervical adenopathy and preoperative planning in the setting of thyroid carcinomas
§ Contrast is recommended as an adjunct to US for members with clinical suspicion for advanced disease, including invasive primary tumor, or clinically apparent multiple or bulky lymph node involvement
¡ Contrast may cause intense and prolonged enhancement of the thyroid gland which interferes with radioactive iodine nuclear medicine studies.
§ Use of IV contrast is an important adjunct because it helps to delineate the anatomic relationship between the primary tumor and metastatic disease. Iodine is generally cleared within four to eight weeks in most members, so concern about iodine burden from IV contrast causing a clinically significant delay in subsequent whole-body scans (WBSs) or radioactive iodine (RAI) treatment after the imaging followed by surgery is generally unfounded. The benefit gained from improved anatomic imaging generally outweighs any potential risk of a several week delay in RAI imaging or therapy. Where there is concern, a urinary iodine to creatinine ratio can be measured.

® MRI Neck is used less frequently than CT Neck.
® MRI Neck without and with contrast (CPT^® 70543) is appropriate if CT suggests the need for further imaging or if ultrasound or CT suggests any of the following:
¡ Neurogenic tumor (schwannoma, neurofibroma, glomus tumor, etc.)
¡ Vascular malformations
¡ Deep neck masses
¡ Angiofibromas

Neck-2: Cerebrovascular and Carotid Disease

For this condition imaging is medically necessary based on the following criteria:

† See these related topics in the Head Imaging Guidelines:

® Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-1.5: General Guidelines – CT and MR Angiography: (CTA and MRA)
® Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-12: Aneurysm and AVM
® Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-21: Stroke/TIA
® Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-22: Cerebral Vasculitis
® Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-23: Dizziness, Vertigo and Syncope
® Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-31: Tinnitus
® Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-32: Eye Disorders

Neck-3: Dysphagia and Esophageal Disorders

Neck-3.1: Dysphagia and Esophageal Disorders

Neck-3.1: Dysphagia and Esophageal Disorders

For this condition imaging is medically necessary based on the following criteria:

† Gastroesophageal Reflux Disease (GERD)⁵

® Advanced imaging is generally not indicated for the evaluation of GERD, the diagnosis of which is usually made on the basis of clinical history, in conjunction with endoscopy, pH monitoring, and occasionally manometry. Exceptions would include the following:
¡ Non-cardiac chest pain suspected of being GERD should be evaluated first to exclude cardiac and other etiologies. See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-4.1: Non-Cardiac Chest Pain-Imaging.
¡ Gastric emptying study (CPT^® 78264) can be approved for members with refractory GERD symptoms, and gastroparesis is being considered..

® Initial imaging is performed with appropriate plain films.
® If imaging is negative, or there is suspicion of a radiolucent foreign body (such as fish or chicken bones, wood, plastic, thin metal objects, aluminum can pop-ups, etc.):
¡ CT Neck and/or Chest with or without contrast
¡ 3-D reconstruction (CPT^® 76377 or CPT^® 76376) can be approved in this setting
® The use of oral contrast is discouraged for acute dysphagia or foreign body impaction, as the contrast may not pass, may be aspirated, and can interfere with subsequent endoscopic intervention.

® Oropharyngeal (difficulty in transferring food from the mouth to the pharynx)
¡ Suspected neurologic causes: See appropriate Head Imaging Guidelines sections in Adult Head Imaging Policy (Policy #151 in the Radiology Section)
¡ Video fluoroscopic swallowing study
® Esophageal dysphagia (difficulty in transferring food down the esophagus in the retrosternal region, e.g. food sticking in the chest)
¡ Initial barium esophagram or upper gastrointestinal endoscopy
¡ Esophageal manometry if indicated
¡ Structural lesions identified on esophagram or endoscopy requiring further evaluation (e.g. tumors, extrinsic compression):
§ CT Neck (CPT^® 70491), CT Chest (CPT^® 71260) and/or CT Abdomen (CPT^® 74160) depending on the level of the lesion.

® CT Neck, Chest, and/or Abdomen, preferably with contrast, as requested, depending on location

® CT Chest (CPT^® 71260), CT Neck (CPT^® 70491), and/or CT Abdomen (CPT^® 74160) depending on location

® See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-12.3: Hiatal Hernia

® Globus sensation is a feeling of a lump or foreign body in the throat. In general, laryngoscopy, endoscopy, and physical examination will rule out malignant causes and advanced imaging is usually not needed for evaluation.
¡ If alarm symptoms are present (dysphagia, weight loss, odynophagia, throat pain, hoarseness, and lateralization of symptoms)
§ Laryngoscopy and upper endoscopy should be performed prior to advanced imaging.
§ CT Neck with contrast (CPT^® 70491) for ANY of the following:
— Negative or equivocal findings on laryngoscopy and upper endoscopy

— Known history of upper aerodigestive or esophageal malignancy

— Known history of lymphoma

— History of previous neck, esophageal, or gastric surgery

— Palpable abnormality on physical examination

® CTA Chest with contrast (CPT^® 71275) can be used in the evaluation of suspected vascular ring
® MRI Chest without contrast, or MRI Chest without and with contrast (CPT^® 71550 or CPT^® 71552), can be performed if vascular ring is suspected

† A detailed history of the dysphagia symptoms is important to distinguish neurogenic, pharyngeal and esophageal disorders

† Dysphagia (difficulty swallowing) can be caused by a wide range of benign and malignant causes that affects the body’s ability to move food or liquid from the mouth to the pharynx and into the esophagus.

† A short duration (weeks to months) of rapidly progressive esophageal dysphagia with associated weight loss is highly suggestive of esophageal cancer.

† Advanced imaging for members presenting with isolated globus rarely impacts clinical management. In a study of 148 neck CTs and 104 barium esophagrams done for the evaluation of globus sensation, there were no malignancies detected.

References
1. Guelfguat M. Clinical Guideline for Imaging and Reporting Ingested Foreign Bodies. American Journal of Roentegneology, 2014, 203;37-53.
2. Takada, M. et. al. 3D-CT diagnosis for ingested foreign bodies. Am J. Emerg Med 2000;18:192-3.
3. ASGE Guideline: Management of Ingested Foreign Bodies and Food Impactions. 2011. Gastrointestinal Endoscopy Vol. 73, No 6.
4. ASGE Guideline: The Role of Endoscopy in the Evaluation and Management of Dysphagia. Gastrointestinal Endoscopy Vol. 79, No 2. 2014.
5. Katz PO, Gerson LB, Vela MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Amer. J. Gastroenterology, 2013; 108:308-328.
6. Liu LWC, Andrews CN, Armstrong D, et al. Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia. Canadian Association of Gastroenterology. Journal of the Canadian Association of Gastroenterology. Vol. 1. Issue 1, 13 April 2018.
7. Lee BE. Globus pharyngeus: A review of its etiology, diagnosis and treatment. World Journal of Gastroenterology. 2012;18(20):2462. doi:10.3748/wjg.v18.i20.2462.
8. ACR Appropriateness Criteria Nontraumatic Aortic Disease. Rev. 2013.
9. ACR Appropriateness Criteria. Known or Suspected Congenital Heart Disease in Adults. Rev. 2016.
10. ACR Appropriateness Criteria Dysphagia. Rev. 2018.
11. Pasha SF, Acosta RD, Chandrasekhara V, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endoscopy. 2014 Feb;79(2):191-201.
12. Poletto E, Mallon MG, Stevens RM, Avitabile CM. Imaging Review of Aortic Vascular Rings and Pulmonary Sling. J Am Osteopath Coll Radiol. 2017;6(2):5-14.
13. Hellinger JC, Daubert M, Lee EY, Epelman M. Congenital Thoracic Vascular Anomalies: Evaluation with State-of-the-Art MR Imaging and MDCT. Radiologic Clinics of North America. 2011;49(5):969-996. doi:10.1016/j.rcl.2011.06.013.

Neck-4: Cervical Lymphadenopathy

Neck-4.1: Imaging

Neck-4.1: Imaging

For this condition imaging is medically necessary based on the following criteria:

See: Neck-5.1: Neck Masses – Imaging

Neck-5: Neck Masses

Neck-5.1: Neck Masses - Imaging

Neck-5.1: Neck Masses - Imaging

For this condition imaging is medically necessary based on the following criteria:

Cervical lymphadenitis is common and follows most viral or bacterial infections of the ears, nose and throat. Painful acute lymphadenopathy should be treated with a trial of conservative therapy for 2 weeks, including antibiotics if appropriate. If there is improvement with conservative treatment, advanced imaging is not indicated but if the adenopathy persists it may be imaged as per below.^1.2.4

Ultrasound (CPT^® 76536) can be considered for ANY of the following:^1,2,4

® Anterior neck masses²
® Cervical adenopathy/lymphadenitis or an inflammatory, infective, or reactive mass that has failed a 2 week trial of treatment or observation (including antibiotics if appropriate)^1,2
® Any ill-defined mass, fullness or asymmetry²
® High suspicion of malignancy^2,4

® Neck mass with high suspicion for malignancy with any ONE of the following:
¡ Non-tender neck masses⁴
¡ Size ≥1.5cm⁴
¡ Firm texture or fixation of the mass⁴
¡ Absence of infectious etiology⁴
¡ 2 or more weeks duration⁴
¡ Cervical adenopathy/lymphadenitis or an inflammatory, infective, or reactive mass that has failed a 2 week trial of treatment or observation (including antibiotics if appropriate)^2,4
¡ Ear pain ipsilateral to the neck mass⁴
¡ Associated onset of persistent hoarseness, tonsil asymmetry, oral or oropharyngeal ulceration, or ulceration of skin overlying the neck mass⁴
¡ History of malignancy that would be primary or metastatic to the neck⁴
¡ Prior ultrasound results are suspicious or indeterminate for malignancy²
® Carcinoma found in a lymph node or other neck mass²
® Suspected peritonsillar, retropharyngeal or other deep neck space abscess²
® Suspected sarcoidosis⁵
® Preoperative evaluation of any neck mass²

® CT suggests the need for further imaging²
® Ultrasound or CT suggests neurogenic tumor (schwannoma, neurofibroma, glomus tumor, etc.), vascular malformations, deep neck masses, or angiofibroma.²

Painful acute lymphadenopathy associated with uncomplicated pharyngitis, URI or tonsillitis should undergo conservative therapy for two weeks including antibiotics, if appropriate. If there is improvement with conservative treatment, advanced imaging is not indicated if:^3,4,5

® Inflammatory neck adenopathy is often associated with URI, pharyngitis, dental infection, HIV and toxoplasmosis. Occasionally it is associated with sarcoidosis and tuberculosis.

ENT evaluation can be helpful in determining the need for advanced imaging.

Although CT and MRI can have characteristic appearances for certain entities, biopsy and histological diagnosis are the only way to obtain a definitive diagnosis. The preferred initial method of biopsy is FNA or Ultrasound guided FNA of the mass.⁵

The most common causes of neoplastic cervical adenopathy are metastasis from head and neck tumors or lymphoma.

References
1. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician. 1998 Oct;58(6):1313-1320.
2. Wippold II F, Cornelius RS, Berger KL, et al. ACR Appropriateness Criteria^® Neck mass/adenopathy. American College of Radiology (ACR). Date or origin: 2009. Revised 2018.
3. Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2012;55(10). doi:10.1093/cid/cis629.
4. Pynnonen MA, Gillespie MB, Roman B, et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary. Otolaryngology–Head and Neck Surgery. 2017;157(3):355-371. doi:10.1177/0194599817723609.
5. Chapman MN, Fujita A, Sung EK, et al. Sarcoidosis in the Head and Neck: An Illustrative Review of Clinical Presentations and Imaging Findings. American Journal of Roentgenology. 2017;208(1):66-75. doi:10.2214/ajr.16.16058.


Neck-6: Malignancies Involving the Neck

For this condition imaging is medically necessary based on the following criteria:

† See the following in the Oncology Imaging Guidelines:
Adult Oncology Imaging Policy (Policy #155 in the Radiology Section);

® ONC-3: Squamous Cell Carcinomas of the Head and Neck
® ONC-4: Salivary Gland Cancers
® ONC-6: Thyroid Cancer
® ONC-9: Esophageal Cancer
® ONC-27: Non-Hodgkin Lymphoma
® ONC-28: Hodgkin Lymphoma

For this condition imaging is medically necessary based on the following criteria:

See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-7: Recurrent Laryngeal Palsy

Neck-8: Thyroid and Parathyroid

Neck-8.1: Thyroid Nodule

Neck-8.2: Hyperthyroidism

Neck-8.3: Parathyroid Imaging

Neck-8.1: Thyroid Nodule

For this condition imaging is medically necessary based on the following criteria:

Serum thyrotropin (TSH) should be measured in the initial evaluation of thyroid nodule/mass/asymmetry/goiter.
† Nuclear scan (CPT^® 78013 or CPT^® 78014) should be performed as the initial imaging study if the serum TSH is subnormal and ANY of the following:

® Single or multiple thyroid nodules^3,6
® Suspicion of ectopic thyroid tissue³
® Presence of thyroid nodule in the setting of Grave’s disease (to rule out cold nodule).³
® Non-diagnostic or indeterminate FNA of thyroid nodule, (e.g. follicular lesion of undetermined significance) to see if hot (functioning) nodule that may be benign vs cold nodule.

® Normal or High serum thyrotropin (TSH)^1,3,6
® Thyroid nodule(s) being monitored with imaging: US is the indicated imaging modality rather than CT or MRI
® Nodules ≤1 cm with very low suspicion US pattern including spongiform pattern and pure cysts do not require repeat US.⁶
® For more suspicious or larger nodules, if Fine Needle Aspiration (FNA) is not performed or was not diagnostic for malignancy, US can be repeated:
¡ If US features are highly suspicious: repeat US every 6 months for up to 24 months.
¡ If US features are of low to intermediate suspicion: repeat US at 12 and 24 months.
¡ If nodule is stable after 24 months, follow-up ultrasound exams (CPT^® 76536) can be performed every 3 to 5 years for interval surveillance.¹²

CT Neck with contrast (CPT^® 70491) or CT Neck without contrast (CPT^® 70490), or MRI Neck without and with contrast (CPT^® 70543). MRI and CT are not indicated for routine thyroid nodule evaluation and should only be considered for:

® Evaluation of extent of known substernal goiter³
® Airway compression³
® Presence of pathologic lymph nodes in cervical regions not visualized on ultrasound³
® Clinically suspected advanced disease confirmed by FNA, including invasive primary tumor^3,6
® Preoperative planning for any thyroid disease

Practice Notes

The basis of thyroid nodule management is the use of ultrasonography (US), thyrotropin (TSH, formerly thyroid-stimulating hormone) assay, and FNA biopsy, together with clinical findings.

Member Features Suggesting Increased Risk for Thyroid Malignancy.

® History of head and neck irradiation
® Family history of medullary thyroid carcinoma, multiple endocrine neoplasia type 2, or papillary thyroid carcinoma
® Age <14 or >70 years
® Male sex
® Growth of the nodule
® Firm or hard nodule consistency
® Cervical adenopathy
® Fixed nodule
® Persistent dysphonia, dysphagia, or dyspnea

There is insufficient evidence supporting the use of PET to distinguish indeterminate thyroid nodules that are benign from those that are malignant.

¹⁸FDG-PET imaging is not routinely recommended for the evaluation of thyroid nodules with indeterminate cytology. Routine preoperative ¹⁸FDG-PET scanning is not recommended.

Neck-8.2: Hyperthyroidism

For this condition imaging is medically necessary based on the following criteria:

Hyperthyroidism suspected^4,7

® Thyroid Uptake Study (CPT^® 78012 or CPT^® 78014) if ONE of the following:
¡ TSH below normal range and elevated free T4 and/or free T3, OR
¡ Subclinical hyperthyroidism with TSH <0.1 mU/L and normal free T4 and free T3.

For this condition imaging is medically necessary based on the following criteria:

Primary Hyperparathyroidism suspected

® Parathyroid Planar Imaging (CPT^® 78070), Parathyroid Planar Imaging with SPECT (CPT^® 78071), Parathyroid Planar Imaging with SPECT and CT (CPT^® 78072) or Ultrasound (CPT^® 76536) if either:
¡ Elevated serum calcium and elevated serum parathyroid hormone level.
¡ Serum calcium 1 mg/dL more over lab normal value
® CT or MRI Neck without and with contrast (CPT^® 70492 or CPT^® 70543):
¡ Very high calcium (≥13) suggesting parathyroid carcinoma
¡ Preoperative localization including 4D CT Neck without and with contrast (CPT^® 70492 or CPT^® 77293).⁷
¡ Recurrent or persistent hyperparathyroidism following neck exploration (MRI preferred).
® CT Chest with contrast may be indicated in rare circumstances in the evaluation of ectopic mediastinal parathyroid adenomas.⁶

A thyroid nodule is distinct either on palpation or radiologically (incidentaloma). Nonpalpable nodules have the same risk of cancer as palpable. Nodules >1 cm are evaluated, while smaller nodules are generally evaluated if suspicious, associated with adenopathy or a history of radiation or cancer exists.

Ultrasound is not used to screen: 1) the general population, 2) members with normal thyroid on palpation with a low risk of thyroid cancer, 3) members with hyperthyroidism, 4) members with hypothyroidism or 5) members with thyroiditis. Conversely, US can be considered in members who have no symptoms but are high risk as a result of: history of head and neck irradiation, total body irradiation for bone marrow transplant, exposure to fallout from radiation during childhood or adolescence, family history, thyroid cancer syndromes such as MEN2, medullary or papillary thyroid cancer, Cowden’s disease, familial adenomatous polyposis, Carney complex, Werner syndrome/progeria.

Radionuclide thyroid scan can be considered to evaluate nodules when hyperthyroidism is present, for surveillance of thyroid cancer, or to detect non-palpable nodules. This scan is not useful for other nodules since hyper functioning nodules rarely harbor malignancy. Thyroid nodules >4 cm may be considered for thyroid lobectomy due to a high incidence of both false negative FNA biopsies and malignancy (26%).

FNA may be repeated after an initial non-diagnostic cytology result, because repeat FNA with US guidance will yield a diagnostic cytology specimen in 75% of solid nodules and 50% of cystic nodules. However, up to 7% of nodules continue to yield non-diagnostic cytology results despite repeated biopsies and may be malignant at the time of surgery.

Thyroid nodules may be stratified as to risk of thyroid cancer based on sonographic findings of microcalcification, hypervascularity on Doppler ultrasound, solid or cystic nature of mass and margins of mass.

Incidental focal FDG-PET uptake often corresponds to a clinically relevant thyroid nodule and ultrasound is recommended; incidentally noted diffuse thyroid FDG-PET uptake most often corresponds to inflammatory uptake, however, ultrasound should be done to ensure that there is no evidence of clinically relevant nodularity.

Elastography provides information about nodule stiffness that is complementary to gray scale ultrasound findings in nodules with indeterminate cytology or ultrasound findings. It should not be used as a substitute for gray scale ultrasound.

Use of ultrasound contrast medium is not recommended for the diagnostic evaluation of thyroid nodules and its current use is restricted to definition of size and limits of necrotic zones after minimally invasive nodule ablation techniques.

References
Thyroid
1. Cooper DS, Doherty GM, Haugen BR et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009 November;19(11):1167-1214.
2. Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR incidental thyroid findings committee. J Am Coll Radiol. 2015 Feb;12(2):143-150.
3. Gharib H, Papini E, Garber JR, et al. American Association Of Clinical Endocrinologists, American College Of Endocrinology, And Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules--2016 update. Endocr Pract. 2016 May;22(Supp 1):1-60..
4. Burch H, Cooper D, Garber J, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. 2011 May-Jun;17(3):456-520.
5. Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission. Thyroid function tests in the diagnoses and monitoring of adults. Effective January 1, 2010.
6. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133.
7. Donangelo I and Suh SY. Subclinical hyperthyroidism: when to consider treatment. Am Fam Physician. 2017 Jun;95(11):710-716.
8. National Comprehensive Cancer Network (NCCN) Guidelines Version 3.2018 – December20, 2018. Thyroid Carcinoma. https://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Thyroid Carcinoma 12.2018. ©2018 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
9. Goiter. American Thyroid Association.
10. Mohebati A and Shaha A. Imaging techniques in parathyroid surgery for primary hyperparathyroidism. Am J Otolaryngol. 2012 Jul-Aug;33(4):457-468.
11. Khan AA, Hanley DA, Rizzoli R, et al. Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus. Osteoporos Int.
12. Grant EG, Tessler FN, Hoang JK, et al. Thyroid ultrasound reporting lexicon: white paper of the ACR thyroid imaging, reporting and data system (TIRADS) committee. J Am Coll Radiology 2015 Dec;12(12) Part A:1272-1279.

Parathyroid
1. Carty SE, Worsey MJ, Virji MA, et al. Concise parathyroidectomy: the impact of preoperative SPECT ^99mTc sestamibi scanning and intraoperative quick parathormone assay. Surgery. 1997 Dec;122(6):1107-1116.
2. Arici C, Cheah WK, Ituarte P, et al. Can localization studies be used to direct focused parathyroid operations? Surgery. 2001 Jun;129(6):720-729.
3. Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg. 2002 May;235(5):665-672.
4. Eslamy HK and Ziessman HA. Parathyroid scintigraphy in patients with primary hyperparathyroidism: ^99mTc sestamibi SPECT and SPECT/CT. RadioGraphics. 2008 Sep-Oct;28(5);1461-1477.
5. Lubitz CC, Stephen AE, Hodin RA, et al. Preoperative localization strategies for primary hyperparathyroidism: an economic analysis. Ann Surg Oncol. 2012 Dec;19(13):4202-4209.
6. Mortenson MM, Evans DB, Lee JE, et al. Parathyroid exploration in the reoperative neck: improved preoperative localization with 4D-computed tomography. J Am Coll Surg. 2008 May;206(5):888-895.
7. Kukar M, Platz TA, Schaffner TJ, et al. The use of modified four-dimensional computed tomography in patients with primary hyperparathyroidism: an argument for the abandonment of routine sestamibi single-positron emission computed tomography (SPECT). Ann Surg Oncol. 2015 Jan;22(1):139-145.

Neck-9: Trachea and Bronchus

Neck-9.1: Trachea and Bronchus - Imaging

Neck-9.1: Trachea and Bronchus - Imaging

For this condition imaging is medically necessary based on the following criteria:

Plain x-rays neck and chest and bronchoscopy are the initial imaging studies for evaluating members with suspected tracheal and visualized bronchial pathology. Bronchoscopy can further evaluate the distal (endo) bronchial tree.

® Suspected tracheal disease can be identified by inspiratory stridor and a characteristic flow-volume loop of PFTs.¹

Expiratory HRCT (CPT^® 71250) is indicated in members with obstructive physiology tracheomalacia.¹

Trachea or bronchial “inspissation” without an abnormality described above, is not a risk for malignancy.³

References
1. Dyer DS, Mohammed T-LH, Kirsch J, et al. ACR Appropriateness Criteria^® Chronic dyspnea: suspected pulmonary origin. Am Coll Radiol (ACR). Date of origin: 1995. Last review date: 2012.
2. Accessed November 16, 2017 https://acsearch.acr.org/docs/69448/Narrative/. Obusez EC, Jamjoom L, Kirsch J, et al. Computed tomography correlation of airway disease with bronchoscopy: part I--nonneoplastic large airway diseases. Curr Probl Diagn Radiol. 2014 Sep-Oct;43(5):268-277. Accessed November 16, 2017. http://www.cpdrjournal.com/article/S0363-0188(14)00038-3/fulltext.
3. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5):e93S-e120S. Accessed November 16, 2017. http://journal.chestnet.org/article/S0012-3692(13)60291-3/fulltext.

Neck-10: Neck Pain

Neck-10.1: Neck Pain (Cervical)

Neck-10.2: Torticollis and Dystonia

Neck-10.1: Neck Pain (Cervical)

For this condition imaging is medically necessary based on the following criteria:

Neck pain is usually related to a specific process including pharyngitis, radiculopathy, adenopathy, mass, carotid dissection and torticollis, and therefore found elsewhere in these guidelines.¹

For the evaluation of neck pain or other symptoms which may involve the cervical spine, including myelopathy and cervical radiculopathy¹ See Adult Spine Imaging Policy (Policy #159 in the Radiology Section)

Neck-10.2: Torticollis and Dystonia

For this condition imaging is medically necessary based on the following criteria:
Older Child (beyond infancy) or Adult¹

For trauma, CT Neck with contrast (CPT^® 70491) and/or CT Cervical Spine without contrast (CPT^® 72125) is the initial study to identify fracture or mal-alignment

For no trauma, CT Neck with contrast (CPT^® 70491), and/or MRI Cervical Spine without contrast (CPT^® 72141), or CT Cervical Spine without contrast (CPT^® 72125) is the initial study to locate a soft tissue or neurological cause

® Positive --> Further advanced imaging is not required if CT Neck or CT Cervical Spine has identified local cause
® Negative --> MRI Brain without and with contrast (CPT^® 70553) to exclude CNS cause

Torticollis or cervical dystonia is an abnormal twisting of the neck with head rotated or twisted. Its causes are many and may be congenital or acquired and caused by trauma, infection/inflammation, neoplasm and those less defined and idiopathic. It occurs more frequently in children and on the right side (75%).

Retropharyngeal space abscess could be associated with torticollis because child would not move neck freely.

References
1. ACR Appropriateness Criteria^® Cervical Neck Pain or Cervical Radiculopathy. Am Coll Radiol (ACR). Date of origin: 1998. Last review date: 2018.
2. Haque S, Shafi BBB, Kaleem M. Imaging of torticollis in children. Radiographics, 2012;32(2):557-571.
3. Boyko N, Eppinger MA, Straka-DeMarco D, Mazzola CA. Imaging of congenital torticollis in infants: a retrospective study of an institutional protocol. Journal of Neurosurgery, 2017;20(2):111-212.

Neck-11: Salivary Gland Disorders

For this condition imaging is medically necessary based on the following criteria:

Xerostomia (Dry Mouth)

® Salivary Gland Nuclear Imaging (one of CPT^® 78230, CPT^® 78231, or CPT^® 78232) can be considered for any one of the following:
¡ Dry mouth and either:
§ Sjögren’s syndrome
§ Sialadenitis
§ History of head or neck radiation therapy
§ History of cerebral palsy
§ Parotid mass to allow preoperative diagnosis of Warthin’s tumor

® CT Neck without contrast (CPT^® 70490) or CT Neck without and with contrast (CPT^® 70492) or CT Maxillofacial area without and with contrast (usually CPT^® 70488) or MRI Neck without and with contrast (CPT^® 70543) for suspected salivary duct or gland stone.
® Sialography (contrast dye injection) under fluoroscopy, may be performed to rule out a stone, with post sialography CT (CPT^® 70486), or post sialography MRI (CPT^® 70540).

® Any ONE of the following can be approved:²
¡ MRI Orbits/Face/Neck without and with contrast (CPT^® 70543)
¡ CT Neck with contrast (CPT^® 70491)
¡ CT Neck without contrast (CPT^® 70490)

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Adult Neck Imaging Policy
Neck Imaging Policy, Adult
Computed Tomography, Neck, Adult
CT, Neck, Adult
Computed Tomography Angiography, Neck, Adult
CTA, Neck, Adult
Magnetic Resonance Imaging, Neck, Adult
MRI, Neck, Adult
Magnetic Resonance Angiography, Neck, Adult
MRA, Neck, Adult
Positron Emission Tomography, Neck, Adult
PET, Neck, Adult
Ultrasound, Neck, Adult
Doppler Studies, Neck, Adult
Duplex Scan, Neck, Adult
Thyroid Imaging, Adult
Parathyroid Imaging, Adult

References:


Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*