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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Radiology
Policy Number:165
Effective Date: 03/10/2020
Original Policy Date:02/23/2016
Last Review Date:02/11/2020
Date Published to Web: 04/13/2016
Subject:
Pediatric Neck Imaging Policy

Description:
_______________________________________________________________________________________

IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

__________________________________________________________________________________________________________________________

TABLE OF CONTENTS

Procedure Codes Associated with Neck Imaging
PEDNECK-1: General Guidelines
PEDNECK-2: Neck Masses (Pediatric)
PEDNECK-3: Cervical Lymphadenopathy
PEDNECK-4: Dystonia/Torticollis
PEDNECK-5: Dysphagia
PEDNECK-6: Thyroid and Parathyroid
PEDNECK-7: Esophagus
PEDNECK-8: Trachea

Procedure Codes Associated with Neck Imaging
MRI
CPT®
Orbit, Face, Neck MRI without contrast
70540
Orbit, Face, Neck MRI with contrast (rarely used)
70542
Orbit, Face, Neck MRI without and with contrast
70543
Temporomandibular Joint (TMJ) MRI
70336
Unlisted MRI procedure (for radiation planning or surgical software)
76498
MRA
CPT®
Neck MRA without contrast
70547
Neck MRA with contrast
70548
Neck MRA without and with contrast
70549
CT
CPT®
Maxillofacial CT without contrast (includes sinuses, jaw, and mandible)
70486
Maxillofacial CT with contrast (includes sinuses, jaw, and mandible)
70487
Maxillofacial CT without and with contrast (includes sinuses, jaw, and mandible)
70488
Neck CT without contrast (includes jaw, and mandible)
70490
Neck CT with contrast (includes jaw, and mandible)
70491
Neck CT without and with contrast (includes jaw, and mandible)
70492
CT Guidance for Placement of Radiation Therapy Fields
77014
Unlisted CT procedure (for radiation planning or surgical software)
76497
CTA
CPT®
Neck CTA
70498
Nuclear Medicine
CPT®
PET Imaging; limited area (this code not used in pediatrics)
78811
PET Imaging: skull base to mid-thigh (this code not used in pediatrics)
78812
PET Imaging: whole body (this code not used in pediatrics)
78813
PET with concurrently acquired CT; limited area (this code rarely used in pediatrics)
78814
PET with concurrently acquired CT; skull base to mid-thigh
78815
PET with concurrently acquired CT; whole body
78816
Thyroid Uptake, Single or Multiple Quantitative Measurement(s) (Including Stimulation, Suppression, or Discharge, When Performed)
78012
Thyroid Imaging (Including Vascular Flow, When Performed)
78013
Thyroid Imaging (Including Vascular Flow, When Performed); with Single or Multiple Uptake(s) Quantitative Measurement(s) (Including Stimulation, Suppression, or Discharge, When Performed)
78014
Thyroid Carcinoma Metastases Imaging Limited Area
78015
Thyroid Carcinoma Metastases Imaging with Additional Studies
78016
Thyroid Carcinoma Metastases Imaging Whole Body
78018
Thyroid Carcinoma Metastases Uptake (Add-on Code)
78020
Parathyroid Planar Imaging (Including Subtraction, When Performed)
78070
Parathyroid Planar Imaging (Including Subtraction, When Performed); with Tomographic (SPECT)
78071
Parathyroid Planar Imaging (Including Subtraction, When Performed); with Tomographic (SPECT), and Concurrently Acquired Computed Tomography (CT) for Anatomical Localization
78072
Salivary Gland Nuclear Imaging
78230
Salivary Gland Nuclear Imaging with Serial Imaging
78231
Salivary Gland Function Study
78232
Esophageal Motility Study
78258
Radiopharmaceutical Localization Imaging Limited Area
78800
Radiopharmaceutical Localization Imaging Whole Body
78802
Radiopharmaceutical Localization Imaging SPECT
78803
Ultrasound
CPT®
Soft tissues of head and neck Ultrasound (thyroid, parathyroid, parotid, etc.)
76536
Duplex scan of extracranial arteries; complete bilateral study
93880
Duplex scan of extracranial arteries; unilateral or limited study
93882
Non-invasive physiologic studies of extracranial arteries, complete bilateral study
93875
Ultrasound guidance for needle placement
76942


Policy:
For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)


PEDNECK-1: General Guidelines

PEDNECK-1.1: Age Considerations
PEDNECK-1.2: Appropriate Clinical Evaluation
PEDNECK-1.3: Modality General Considerations

This General Policy section provides an overview of the basic criteria for which Pediatric 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.

PEDNECK-1.1: Age Considerations

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

Many conditions affecting the neck in the pediatric population are different diagnoses than those occurring in the adult population. For those diseases which occur in both pediatric and adult populations, minor differences may exist in management due to member age, comorbidities, and differences in disease natural history between children and adults.

Members who are <18 years old should be imaged according to the Pediatric Neck Imaging Guidelines, and members who are ≥18 years old should be imaged according to the Adult Neck Imaging Guidelines, except where directed otherwise by a specific guideline section.

PEDNECK-1.2: Appropriate Clinical Evaluation

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

A recent (within 60 days) face to face evaluation including a detailed history, physical examination, and appropriate laboratory studies should be performed prior to considering advanced imaging (CT, MRI, Nuclear Medicine), unless the member is undergoing guideline-supported scheduled follow-up imaging evaluation.

Unless otherwise stated in a specific guideline section, the use of advanced imaging to screen asymptomatic members for disorders involving the neck is not supported. Advanced imaging of the neck should only be approved in members who have documented active clinical signs or symptoms of disease involving the neck.

Unless otherwise stated in a specific guideline section, repeat imaging studies of the neck are not necessary unless there is evidence for progression of disease, new onset of disease, and/or documentation of how repeat imaging will affect member management or treatment decisions.

PEDNECK-1.3: Modality General Considerations

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

MRI

    ® MRI Neck is generally performed without and with contrast (CPT® 70543) unless the member has a documented contraindication to gadolinium or otherwise stated in a specific guideline section.
    ® Due to the length of time required for MRI acquisition and the need to minimize member movement, anesthesia is usually required for almost all infants (except neonates) and young children (age <7 years) as well as older children with delays in development or maturity. This anesthesia may be administered via oral or intravenous routes. In this member population, MRI sessions should be planned with a goal of minimizing anesthesia exposure by adhering to the following considerations:
      ¡ MRI procedures can be performed without and/or with contrast use as supported by these condition based guidelines. If intravenous access will already be present for anesthesia administration and there is no contraindication for using contrast, imaging without and with contrast may avoid repetitive anesthesia administration to perform an MRI with contrast if the initial study without contrast is inconclusive.
        Recent evidence based literature demonstrates the potential for gadolinium deposition in various organs including the brain, after the use of MRI contrast.
        The U.S. Food and Drug Administration (FDA) has noted that there is currently no evidence to suggest that gadolinium retention in the brain is harmful and restricting gadolinium-based contrast agents (GBCAs) use is not warranted at this time. It has been recommended that GBCA use should be limited to circumstances in which additional information provided by the contrast agent is necessary and the necessity of repetitive MRIs with GBCAs should be assessed.
      ¡ If multiple body areas are supported by Horizon BCBSNJ guidelines for the clinical condition being evaluated, MRI of all necessary body areas should be obtained concurrently in the same anesthesia session.
    ® The presence of surgical hardware or implanted devices may preclude MRI.
    ® The selection of best examination may require coordination between the provider and the imaging service.

CT
    ® CT Neck typically extends from the base of the skull to the upper thorax.
      ¡ A separate CPT® code for head imaging in order to visualize the skull base is not necessary.
      ¡ In some cases, especially in follow-up of a known finding, it may be appropriate to limit the exam to the region of concern to reduce radiation exposure.
    ® CT Neck is generally performed with contrast (CPT® 70491) unless the member has a documented contraindication to CT contrast or otherwise stated in a specific guideline section.
    ® CT Neck may be indicated for further evaluation of abnormalities suggested on prior US or MRI Procedures.
    ® In general, CT Neck is appropriate when evaluating trauma, malignancy, and for preoperative planning.
    ® CTA Neck (CPT® 70498) is indicated for evaluation of the vessels of the neck, especially with concern for dissection.
    ® CT should not be used to replace MRI in an attempt to avoid sedation unless listed as a recommended study in a specific guideline section.
    ® The selection of best examination may require coordination between the provider and the imaging service.

Ultrasound
    ® Ultrasound soft tissues of the neck (CPT® 76536) is indicated as an initial study for evaluating adenopathy, other palpable mass or swelling, thyroid, parathyroid, parotid and other salivary glands, and cysts.
    ® For those members who do require additional advanced imaging after ultrasound, ultrasound can be very beneficial in selecting the proper modality, body area, image sequences, and contrast level that will provide the most definitive information for the member.

Nuclear Medicine
    ® Nuclear medicine studies of the neck in pediatric members are most commonly used to evaluate neck masses, or thyroid and parathyroid disease following initial studies with anatomic imaging, such as ultrasound, CT, or MRI. See PEDNECK-2: Neck Masses (Pediatric) and PEDNECK-6: Thyroid and Parathyroid for imaging guidelines.
    ® Salivary Gland Nuclear Imaging (one of CPT® 78230, CPT® 78231, or CPT® 78232) is indicated for the following:
      ¡ Evaluation of salivary gland function in members with dry mouth (xerostomia) and ONE of the following:
        Sjögren syndrome
        Sialadenitis
        History of head or neck radiation therapy
The guidelines listed in this section for certain specific indications are not intended to be all-inclusive; clinical judgment remains paramount and variance from these guidelines may be appropriate and warranted for specific clinical situations.

References

1. Siegel MJ. Neck sonography. In: Pediatric sonography. 5th ed. Philadelphia. Wolters Kluwer 2018 pp112-155
2. Meier JD, and Grimmer JF. Evaluation and management of neck masses in children. Am Fam Physician. 2014; 89:353-358.
3. Biassoni L, Easty M. Paediatric nuclear medicine imaging. British Medical Bulletin. 2017;123(1):127-148. doi:10.1093/bmb/ldx025.
4. Bridges MD, Berland LL, Friedberg EB, et al. ACR Practice parameter for performing and interpreting magnetic resonance imaging (MRI). American College of Radiology. Revised 2017 (Resolution 10).
5. Karmazyn BK, John SD, Siegel MJ, et al. ACR–ASER–SCBT-MR–SPR Practice parameter for the performance of pediatric computed tomography (CT). American College of Radiology. Revised 2014 (Resolution 3).
6. Ing C, DiMaggio C, Whitehouse A et al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics. 2012 Sep; 130 (3): e476-e485.
7. Monteleone M, Khandji A, Cappell J, et al. Anesthesia in children: perspectives from nonsurgical pediatric specialists. J Neurosurg Anesthesiol. 2014 Oct; 26 (4): 396-398..
8. DiMaggio C, Sun LS, and Li G. Early childhood exposure to anesthesia and risk of developmental and behavioral disorders in a sibling birth cohort. Anesth Analg. 2011 Nov; 113 (5):1143-1151.
9. MacDonald A and S Burrell. Infrequently performed studies in nuclear medicine: part 2*. J Nucl Med Technol. 2009 Mar; 37 (1): 1-13.
10. Fraum TJ, Ludwig DR., Bashir MR, et al. Gadolinium-based contrast agents: a comprehensive risk assessment. J. Magn. Reson. Imaging. 2017 Aug; 46 (2):338–353.
11. FDA Medical Imaging Drug Advisory Committee meeting 9/8/17 Minutes available at https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/MedicalImagingDrugsAdvisoryCommittee/UCM574746.pdf.
12. Blumfield, Einat, David W. Swenson, Ramesh S. Iyer, and A. Luana Stanescu. "Gadolinium-based Contrast Agents — Review of Recent Literature on Magnetic Resonance Imaging Signal Intensity Changes and Tissue Deposits, with Emphasis on Pediatric Patients." Pediatric Radiology 49, no. 4 (2019): 448-57. doi:10.1007/s00247-018-4304-8.


PEDNECK-2: Neck Masses (Pediatric)

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

Evaluation of neck masses in pediatric members involves careful consideration of clinical history and accurate physical examination. The member's age and knowledge of the anatomy and common lesions of the neck are very important in narrowing the differential diagnosis.

Ultrasound Neck (CPT® 76536) is indicated as the initial imaging study of choice. Ultrasound helps define the size and extent of localized superficial masses and helps confirm whether they are cystic or solid. Color Doppler ultrasound (CPT® 93880 bilateral study or carotid arteries or CPT® 93882 unilateral study) can evaluate the vasculature.

MRI Neck without contrast (CPT® 70540) or without and with contrast (CPT® 70543), or CT Neck with contrast (CPT® 70491) can be approved if ultrasound is inconclusive or to further characterize abnormalities seen on ultrasound.

Cervical lymphadenitis is common in children and follows most viral or bacterial infections of the ears, nose, and throat. No advanced imaging is necessary with uncomplicated lymph node enlargement. When lymphadenopathy persists for more than 4 weeks of treatment or there is suspicion of complications, such as abscess formation, ultrasound is indicated, See PEDNECK-3: Cervical Lymphadenopathy.

Congenital cervical cysts frequently present in children and include thyroglossal duct cyst (55% of cases), cystic hygroma (25%), branchial cleft cysts (16%), bronchogenic cyst (0.91%), and thymic cyst (0.3%).

    ® Barium swallow and MRI Neck without and with contrast (CPT® 70543) or CT Neck with contrast (CPT® 70491) are indicated for diagnosis of fourth branchial cleft cysts.
    ® Ultrasound is indicated for initial evaluation of a suspected cystic neck mass.
    ® MRI Neck without and with contrast (CPT® 70543) or CT Neck with contrast (CPT® 70491) may be indicated for preoperative planning.

Salivary gland nuclear imaging (one of CPT® 78230, CPT® 78231, or CPT® 78232) is indicated for evaluation of parotid masses to allow preoperative diagnosis of Warthin’s tumor.

Practice Notes

The most common malignant ENT tumors in children are lymphoma and rhabdomyosarcoma.

Differential Diagnosis of Neck Lesions by Anatomic Region:

Subcutaneous tissues:

    ® Teratoma (includes dermoid cysts)
      ¡ Cervical teratomas are typically large bulky masses discovered at birth or in the first year of life.
      ¡ Large lesions may cause stridor, dyspnea, or dysphagia.
      ¡ Most teratomas arise in the anterior suprahyoid neck and may be midline or off midline in location and adjacent to or within a thyroid lobe.
    ® Vascular malformations
    ® Lipoma
    ® Cellulitis
    ® Plexiform neurofibromas
    ® Keloid
    ® Scar
    ® Pilomatrixoma
    ® Subcutaneous fat fibrosis (in neonates)

Retropharyngeal space:
    ® Abscess, cellulitis, adenitis
      ¡ Usually involves children under age 6.
      ¡ Members have history of upper respiratory tract infection followed by high fever, dysphagia, and neck pain.
    ® Lymphadenopathy
    ® Extension of goiter
    ® Extension of pharyngeal tumor

Retrovisceral space (posterior to the cervical esophagus):
    ® Gastrointestinal duplication cysts (usually are diagnosed in first year of life).

Pretracheal space (contains trachea, larynx, cervical esophagus, recurrent laryngeal nerves, and thyroid and parathyroid glands):
    ® Thyroglossal duct cyst
      ¡ Thyroglossal duct cyst is most common before the age of 20, 75% present as a midline mass and 43% of members present with an infected mass.
      ¡ Usually presents as an enlarging, painless midline mass.
      ¡ Thyroid carcinoma occurs in 1% of thyroglossal duct cysts.
    ® Goiter
    ® Laryngocele
    ® Lymphadenopathy
    ® Teratoma
    ® Abscess
    ® Extopic thymus or cervical extension of normal thymus

Danger space (closed space lying between the skull base and the posterior mediastinum and between the alar and prevertebral fasciae in a sagittal plane):
    ® Cellulitis
    ® Abscess

Prevertebral space:
    ® Neurenteric cyst
    ® Cellulitis
    ® Abscess
    ® Spondylodiskitis
    ® Lymphadenopathy
    ® Cellulitis
    ® Paraganglioma

Carotid sheath space:
    ® Jugular vein thrombosis or phlebitis
    ® Lymphadenopathy
    ® Cellulitis
    ® Abscess
    ® Paraganglioma

Parotid gland space:
    ® Parotid lymphadenopathy
    ® Retromandibular vein thrombosis
    ® Parotiditis
    ® Sialodochitis (inflammation of the salivary gland duct)
    ® Salivary duct stone

Submandibular and sublingual spaces:
    ® Thyroglossal duct cyst
    ® Branchial cleft cyst
      ¡ 90% of branchial abnormalities arise from the second branchial apparatus.
      ¡ Second branchial cleft cysts are the most common branchial cleft cyst and usually present in members between 10 and 40 years as painless fluctuant masses.
      ¡ They typically present as slowly growing, nontender masses in the upper neck
      ¡ Most second branchial cleft cysts are located in the submandibular space, at the anteromedial border of the sternocleidomastoid muscle, lateral to the carotid space, or posterior to the submandibular gland.
      ¡ Ranula – typically cystic masses in the floor of the mouth.
Masticator space (includes masseter and pterygoid muscles):
    ® Venous or lymphatic malformation
    ® Cellulitis
    ® Abscess
    ® Rhabdomyosarcoma

Parapharyngeal space:
    ® Cellulitis
    ® Abscess
    ® Rhabdomyosarcoma
    ® Extension of lymphoma

Paravertebral space:
    ® Cervical dermal sinus (epithelium-lines dural tubes that connect the skin with the central nervous system or its covering)
    ® Meningocele
    ® Rhabdomyosarcoma
    ® Lymphoma
    ® Neuroblastoma
    ® Neurofibroma

Posterior cervical space:
    ® Lymphadenopathy
    ® Lymphatic malformation

References

1. Siegel MJ. Neck sonography. In: Pediatric sonography. 5th ed. Philadelphia. Wolters Kluwer 112-155.
2. Geddes G, Butterly MM, Patel SM, et al. Pediatric Neck Masses. Pediatr Rev. 2013 Mar 1; 34(3):115-125.
3. Ludwig BJ, Wang J, Nadgir RN, et al. Imaging of cervical lymphadenopathy in children and young adults. Am J Roentgenol. 2012 Nov; 199 (5):1105-1113.
4. Rizzi MD, Wetmore RF, Potsic WP. Differential diagnosis of neck masses. In: Lesperance MM, Flint PW, eds. Cummings Pediatric Otolaryngology, Philadelphia: Saunders Company, 2015; 245-254.
5. Bansal AG, Oudsema R, Masseaux JA, Rosenberg HK. US of Pediatric Superficial Masses of the Head and Neck. RadioGraphics. 2018;38(4):1239-1263. doi:10.1148/rg.2018170165.
6. Kelly TG, Faulkes SV, Pierre SK, et al. Imaging submandibular pathology in the paediatric patient. Clinical Radiol. 2015 Jul;70(7):774-786.
7. Collins B, Stoner JA, and Digoy GP. Benefits of ultrasound vs. computed tomography in the diagnosis of pediatric lateral neck abscesses. Int J Pediatr Otorhinolaryngol. 2014 Mar; 78 (3): 423-426.
8. MacDonald A and S Burrell. Infrequently performed studies in nuclear medicine: part 2*. J Nucl Med Technol. 2009 Mar; 37 (1): 1-13.
9. Stern JS, Ginat DT, Nicholas JL, Ryan ME. Imaging of Pediatric Head and Neck Masses. Otolaryngologic Clinics of North America. 2015;48(1):225-246.
10. ACR Appropriateness Criteria. Neck Mass/Adenopathy. Rev. 2018.
11. Brown, Ruth Elizabeth, and Srikrishna Harave. "Diagnostic Imaging of Benign and Malignant Neck Masses in Children—a Pictorial Review." Quantitative Imaging in Medicine and Surgery 6, no. 5 (2016): 591-604. doi:10.21037/qims.2016.10.10.

PEDNECK-3: Cervical Lymphadenopathy

PEDNECK-3.1: Imaging
PEDNECK-3.1: Imaging

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

Painful acute lymphadenopathy and other painful neck masses (including neck “swelling”) should be treated with a trial of conservative therapy for at least 4 weeks, including antibiotics if appropriate.

    ® If there is improvement with conservative treatment, advanced imaging is not indicated.
    ® If there is unexplained fever with a temperature ≥100.4°F and there is clinical concern for suppurative lymphadenopathy or a neck abscess, ultrasound (CPT® 76536) is indicated without 4 weeks of treatment and observation.

Ultrasound Neck (CPT® 76536) is indicated as an initial evaluation if lymphadenopathy persists following 4 weeks of treatment and/or observation.

MRI Neck without contrast (CPT® 70540) or without and with contrast (CPT® 70543) or CT Neck with contrast (CPT® 70491) can be approved if ultrasound is inconclusive or to further characterize abnormalities seen on ultrasound. Both are superior to ultrasound for defining the relationship of an abscess to adjacent structures, particularly the airway; and detecting posterior cervical, mediastinal and intracranial extension.

If systemic symptoms or other clinical findings suggest malignancy, See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-5: Pediatric Lymphomas in the Pediatric Oncology Imaging Guidelines.

Practice Notes
Inflammatory lymph nodes from acute lymphadenitis are usually painful, tender and mobile, frequently associated with upper respiratory infection, pharyngitis or dental infection.

Occasionally, sarcoidosis or toxoplasmosis and Human immunodeficiency virus (HIV) can cause inflammatory lymphadenopathy as well.

References

1. Ludwig BJ, Wang J, Nadgir RN, et al. Imaging of cervical lymphadenopathy in children and young adults. Am J Roentgenol. 2012 Nov; 199 (5):1105-1113.
2. Nodler AR. Paediatric cervical lymphadenopathy: when to biopsy? Curr Opin Otolaryngol Head Neck Surg 2013; 21:567-570.
3. Ellika SK, Chadha M, and Yang Z. Imaging in nontraumatic pediatric head and neck emergencies. J Pediatr Neurol. 2017 Jul 27;15(5):263-293.
4. Rosenberg TL, Nolder AR. Pediatric Cervical Lymphadenopathy. Otolaryngologic Clinics of North America. 2014;47(5):721-731.
5. Weinstock MS, Patel NA, Smith LP. Pediatric Cervical Lymphadenopathy. Pediatrics in review. 2018 Sep;39(9):433-43.
6. ACR Appropriateness Criteria. Neck Mass/Adenopathy. Revised 2018.


PEDNECK-4: Dystonia/Torticollis

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

Infants under 12 Months of Age (Congenital Muscular Torticollis)

Ultrasound Neck (CPT® 76536) is indicated as the initial study to evaluate suspected congenital muscular torticollis, also called fibromatosis coli.

    ® Members usually present by 2 weeks of life with an anterior neck mass, which is commonly right sided (75% of cases). A history of a traumatic breech or forceps delivery is common.
    ® If Ultrasound is Positive No further imaging is needed since diagnosis is defined.
    ® If Ultrasound is Negative CT Neck with contrast (CPT® 70491) or MRI Neck without contrast (CPT® 70540) or without and with contrast (CPT® 70543) can be approved to evaluate for other structural causes.

Children and Adults (Acquired Torticollis)

Injury or inflammation involving the sternocleidomastoid or trapezius muscles is the most common cause of acquired torticollis in children.

If there has been recent trauma, plain radiographs of the cervical spine should be obtained as an initial evaluation when the suspicion of injury is low. CT Neck with contrast (CPT® 70491) and/or CT Cervical Spine without contrast (CPT® 72125) is indicated as the initial study to identify fracture or malalignment if plain radiographs are inconclusive or in members with a high risk mechanism of cervical spine injury within the last 3 months (See below**). MRI Cervical Spine without contrast (CPT® 72141) is also appropriate in the clinical setting of cervical spine trauma with an associated neurologic deficit.

In the absence of trauma, CT Neck with contrast (CPT® 70491), CT Cervical Spine without contrast (CPT® 72125), MRI Cervical Spine without contrast (CPT® 72141), MRI Neck without and with contrast (CPT® 70543), or MRA Neck without and with contrast (CPT® 70549) can be approved to identify underlying abscess, bony, muscular, vascular, or neurologic causes.

    ® Positive Further advanced imaging is not required if a local cause has been identified.
    ® Negative MRI Brain without and with contrast (CPT® 70553) to exclude CNS cause.

**High risk mechanisms of cervical spine injury may include:
    ® Head trauma and/or maxillofacial trauma
    ® Pedestrian in a motor vehicle accident
    ® Fall from above standing height
    ® Diving accident
    ® Head-on motor vehicle collision without/with airbag deployment
    ® Rollover motor vehicle collision
    ® Ejection from the vehicle in a motor vehicle collision
    ® High speed of the vehicle at the time of collision
    ® Not wearing a seatbelt/shoulder harness in a motor vehicle collision
    ® Members with ankylosing spondylitis are at high risk of cervical spine fractures even with minor direct/indirect trauma to the cervical spine which can result in quadriparesis/quadriplegia

Practice Note
Torticollis or cervical dystonia is an abnormal twisting of the neck in which the head is rotated or twisted. Acute causes are most common. Other causes are variable and may be congenital, acquired (caused by trauma, juvenile idiopathic arthritis, or neoplasm), or idiopathic. Imaging approach is same as that for acute torticollis in children.

References

1. Dudkiewicz I, Ganel A, and Blankstein A. Congenital muscular torticollis in infants: ultrasound-assisted diagnosis and evaluation. J Pediatr Orthop. 2005 Nov-Dec; 25 (6):812-814.
2. Suhr MC and Oledzka M. Considerations and intervention in congenital muscular torticollis. Curr Opin Pediatr. 2015 Feb; 27 (1):75-81.
3. Haque S, Shafi BBB, and Kaleem M. Imaging of torticollis in children. RadioGraphics. 2012 Mar-Apr; 32 (2): 557-571. http://pubs.rsna.org/doi/full/10.1148/rg.322105143.
4. ACR APPROPRIATENESS CRITERIA Suspected Spine Truama-Child. Revised 2018.


PEDNECK-5: Dysphagia

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

Dysphagia imaging indications in pediatric members are very similar to those for adult members. See Adult Neck Imaging Policy (Policy #153 in the Radiology Section); Neck-3: Dysphagia and Esophageal Disorders in the Neck Imaging Guidelines.

Pediatric-specific imaging considerations include the following:

    ® X-rays neck and chest may be appropriate as the initial imaging study when concerned for foreign body ingestion as cause of dysphagia.
    ® Esophageal motility study (CPT® 78258) is indicated for ANY of the following:
      ¡ Dysphagia associated with chest pain and difficulty swallowing both solids and liquids.
      ¡ Gastroesophageal reflux.
CTA Chest (CPT® 71275) or MRA Chest (CPT® 71555) is indicated for a suspected vascular ring, which can be associated with dysphagia:
    ® A right aortic arch or double arch noted on chest radiography is an indication for CTA or MRA.

References

1. Kakodkar K and Schroeder Jr JW. Pediatric dysphagia. Pediatr Clin N Am. 2013 Aug; 60(4):969-977.
2. Stagnaro N, Rizzo F, Torre M, Cittadini G, Magnano G. Multimodality imaging of pediatric airways disease: indication and technique. La radiologia medica. 2017;122(6):419-429.
3. Dodrill P, Gosa MM. Pediatric Dysphagia: Physiology, Assessment, and Management. Ann Nutr Metab 2015; 66:24–31.


PEDNECK-6: Thyroid and Parathyroid

PEDNECK-6.1: Thyroid Masses or Nodules
PEDNECK-6.2: Hyperthyroidism
PEDNECK-6.3: Hypothyroidism
PEDNECK-6.4: Parathyroid Imaging

PEDNECK-6.1: Thyroid Masses or Nodules

PEDNECK-6.1: Thyroid Masses or Nodules

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

Ultrasound Neck (CPT® 76536) is the recommended initial study for evaluation of thyroid masses or nodules in pediatric members.

    ® If TSH normal or elevated, fine needle aspiration (FNA) under ultrasound guidance (CPT® 76942) is indicated.
    ® If TSH is low, nuclear thyroid scintigraphy (either CPT® 78013 or CPT® 78014), is indicated.
      ¡ Hyperfunctioning nodules should be resected surgically.
      ¡ Hypofunctioning nodules should undergo FNA under ultrasound guidance (CPT® 76942).
CT Neck without contrast (CPT® 70490) or with contrast (CPT® 70491), or MRI Neck without contrast (CPT® 70540) or without and with contrast (CPT® 70543) is indicated for preoperative planning in members with large or fixed masses, vocal cord paralysis, or bulky cervical or supraclavicular adenopathy.
    ® CT Chest without contrast (CPT® 71250) or with contrast (CPT® 71260) is also indicated for members with substernal extension of the thyroid, pulmonary symptoms, or abnormalities on recent chest x-ray.

If any biopsy reveals thyroid carcinoma, See Adult Oncology Imaging Policy (Policy #155 in the Radiology Section); ONC-6: Thyroid Cancer in the Oncology Imaging Guidelines.

If the biopsy shows indeterminate findings, repeat ultrasound (CPT® 76536) and/or FNA (CPT® 76942) is indicated 3 months following initial biopsy.

    ® If the nodule is stable and/or FNA is benign, repeat ultrasound (CPT® 76536) is indicated in 6 months.
    ® If the nodule is growing or the FNA is not benign, the nodule should be resected surgically.

If the initial biopsy shows benign findings, repeat ultrasound (CPT® 76536) is indicated 6 months following initial biopsy.
    ® If the nodule is stable, repeat ultrasound (CPT® 76536) is indicated annually.
    ® If the nodule is growing or concerning new findings are present, the nodule should undergo repeat FNA (CPT® 76942) or be resected surgically.
    ® Benign nodules that have been surgically resected do not require routine imaging follow up in the absence of clinical or laboratory changes suggesting recurrence.

PEDNECK-6.2: Hyperthyroidism

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

Ultrasound Neck (CPT® 76536) is the recommended initial study for evaluation of hyperthyroidism. Common causes are Graves’ disease and autoimmune disorders (lupus, rheumatoid arthritis and Sjogren syndrome).

    ® If a nodule or mass is discovered on ultrasound, the member should be imaged according to PEDNECK-6.1: Thyroid Masses or Nodules.

For all other members with documented hyperthyroidism, thyroid uptake nuclear imaging (either CPT® 78012 or CPT® 78014) is indicated.

PEDNECK-6.3: Hypothyroidism

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

Causes include thyroid congenital dysgenesis, dyshormonogenesis autoimmune thyroiditis, Hashimoto thyroiditis, subacute thyroiditis, and abnormality in the pituitary gland or hypothalamus. Congenital hypothyroidism is usually diagnosed in the neonate on a routine perinatal screening examination.

Ultrasound (CPT® 76536) is the recommended initial study for evaluation of hypothyroidism.

    ® If a nodule or mass is discovered on ultrasound, the member should be imaged according to PEDNECK-6.1: Thyroid Masses or Nodules.

For members with documented congenital hypothyroidism, thyroid uptake nuclear imaging (either CPT® 78012 or CPT® 78014) is indicated.

PEDNECK-6.4: Parathyroid Imaging

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

Either ultrasound (CPT® 76536) or sestamibi parathyroid nuclear imaging (one of CPT® 78070, CPT® 78071, or CPT® 78072) is indicated for initial evaluation of primary or recurrent hyperparathyroidism, generally indicated by one of the following:

    ® Serum calcium (>1 mg/dL over upper limit of normal).
    ® Elevated serum calcium and elevated serum parathyroid hormone (PTH).

CT Neck without and with contrast (CPT® 70492) or MRI Neck without contrast (CPT® 70540) or without and with contrast (CPT® 70543) is indicated for any of the following:
    ® Preoperative planning for localization.
    ® Serum calcium (>1 mg/dL over upper limit of normal).
    ® Recurrent or persistent hyperparathyroidism following neck exploration (MRI preferred unless contraindicated).

References

1. Waguespack SG, Huh WW, and Bauer AJ. Endocrine tumors. In: Pizzo PA, Poplack DG, eds. Principles and Practices of Pediatric Oncology. 7th ed. Wolters Kluwer. Philadelphia, PA. 2016;919-945.
2. LaFranchi SH, Haung SA. Hypothyroidism. Nelson Textbook of Pediatrics, Chapter 565. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016. pp. 2665-2675.
3. LaFranchi SH, Haung SA. Solitary thyroid nodule. Nelson Textbook of Pediatrics, Chapter 569. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016. pp. 2686-2687.
4. LaFranchi SH, Haung SA. Throiditis. Nelson Textbook of Pediatrics, Chapter 566. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016. pp. 2675-2677.
5. LaFranchi SH, Haung SA. Hyperthyroidism. Nelson Textbook of Pediatrics, Chapter 568. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016. pp. 2680-2685.
6. Doyle DA. Hypoparathyroidism. Nelson Textbook of Pediatrics, Chapter 571. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016. pp 2690-2693.
7. Doyle DA. Hyperparathyroidism. Nelson Textbook of Pediatrics, Chapter 573. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016. pp. 2694-2697.
8. Francis GL, Waguespack SG, Bauer AJ, et al. Management guidelines for children with thyroid nodules and differentiated thyroid cancer. Thyroid. 2015 Jul; 25 (7): 716-759.
9. Essenmacher AC, Joyce PH, Kao SC, et al. Sonographic Evaluation of Pediatric Thyroid Nodules. RadioGraphics. 2017;37(6):1731-1752.
10. Williams JL, Paul DL, Bisset G. Thyroid disease in children: part 1. Pediatric Radiology. 2013;43(10):1244-1253.
11. Williams JL, Paul D, Bisset G. Thyroid disease in children: part 2. Pediatric Radiology. 2013;43(10):1254-1264
12. Papendieck P, Gruñiero-Papendieck L, Venara M, et al. Differentiated thyroid cancer in children: prevalence and predictors in a large cohort with thyroid nodules followed prospectively. J Pediatr. 2015 Jul; 167 (1):199-201.
13. Bahn RS, Burch HB, Cooper DS, 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; 17 (3): 456-520.
14. Donangelo I, and Braunstein GD. Update on subclinical hyperthyroidism. Am Fam Physician. 2011; 83 (8):933-938.
15. Gharib H, Papini E, Paschke R, et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrionologi, and European Thyroid Association. Medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract. 2010 May-Jun; 16 (Suppl 1): 1-43.
16. American Academy of Pediatrics, Susan R. Rose, American Thyroid Association, Rosalind S. Brown, Lawson Wilkins Pediatric Endocrine Society and the Section on Endocrinology and Committee on Genetics, and the Public Health Committee. Update on newborn screening and therapy for congenital hypothyroidism. Pediatrics. 2006 Jun; 117 (6): 2290-2303.
17. Bilezikian JP, Khan AA, and Potts Jr JT. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. J Clin Endocrinol Metab. 2009; 94 (2): 335-339.
18. Greenspan BS, Dillehay GL, and Intenzo C. SNM practice guideline for parathyroid scintigraphy 4.0*. J Nucl Med Technol. 2012 Jun 1; 40 (2): 111-118.
19. Sung, Jin Yong. "Parathyroid Ultrasonography: The Evolving Role of the Radiologist." Ultrasonography 34, no. 4 (2015): 268-74. doi:10.14366/usg.14071.


PEDNECK-7: Esophagus

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

Esophagus imaging indications in pediatric members are very similar to those for adult members. See Adult Neck Imaging Policy (Policy #153 in the Radiology Section); Neck-3: Dysphagia and Esophageal Disorders in the Neck Imaging Guidelines.

Pediatric-specific imaging considerations include the following:

    ® Esophagram is the study of choice for evaluating congenital atresia with associated tracheoesophageal fistula.
    ® Plain radiographs alone usually suffice for the diagnosis of other types of esophageal atresia and a contrast examination of the esophagus is not warranted but may be indicated for post-operative evaluation.
    ® CT Neck with contrast (CPT® 70491) and CT Chest with contrast (CPT® 71260) are indicated for evaluation of suspected congenital malformations if x-rays or esophagram are inconclusive.
      ¡ 3D rendering may be approvable for preoperative planning in complex cases.
References

1. Hryhorczuk AL, Lee EY, Eisenberg RL. Esophageal Abnormalities in Pediatric Patients. AJR 2013; 201:W519-W532.
2. Seekins JM, et al. Esophagus congenital and neonatal abnormalities. Chapter 97. Caffey’s Pediatric Diagnostic Imaging. eds. Coley B, Saunders E, Philadelphia PA, 2013. p 12.
3. Ellis WE Esophagus: Congenital and Neonatal Abnormalities. Chapter 96. Caffey’s Pediatric Diagnostic Imaging 13th Edition. ed. Coley B Philadelphia PA, 2018. p 901-910


PEDNECK-8: Trachea

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

Trachea imaging indications in pediatric members are very similar to those for adult members. See Adult Neck Imaging Policy (Policy #153 in the Radiology Section); Neck-9: Trachea and Bronchus in the Neck Imaging Guidelines.

Pediatric-specific imaging considerations include the following:

    ® CT Neck with contrast (CPT® 70491) and CT Chest with contrast (CPT® 71260) are indicated for evaluation of suspected congenital malformations if x-rays are inconclusive.
      ¡ 3D rendering may be approvable for preoperative planning in complex cases.
      ¡ CT is not routinely performed to evaluate foreign body aspiration, but it may be considered in complicated cases.
References

1. Pugmire BS, Lim R, and Avery LL. Review of Ingested and aspirated foreign bodies in children and their clinical significance for radiologists. RadioGraphics. 2015; 35:1528-1538.
2. Lee EY, Restrepo R, Dillman JR, et al. Imaging evaluation of pediatric trachea and bronchi: systematic review and updates. Semin Roentgenol. 2012 Apr; 47 (2):182-196.
3. Lee EY. Lower large airway disease. Chapter 52. Caffey’s Pediatric Diagnostic Imaging. eds. Coley B,. Philadelphia PA, 2018. p486-494.
4. Semple T, Calder A, Owens C, Padley S. Current and future approaches to large airways imaging in adults and children. Clinical Radiology. 2017;72(5):356-374.
5. Stagnaro N, Rizzo F, Torre M, Cittadini G, Magnano G. Multimodality imaging of pediatric airways disease: indication and technique. La radiologia medica. 2017;122(6):419-429.

Medicaid Coverage:

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

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*

    HCPCS

    * CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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    Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

    The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy

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