Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy Form


Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy

Subject:

Description

This document addresses the diagnostic use of fiberoptic flexible laryngoscopy (FFL). This diagnostic procedure utilizes a flexible scope for visualization of the larynx, pharynx and related structures.

Notes:

  • Please see the following documents for related information: 
    • CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
    • CG-SURG-57 Diagnostic Nasal Endoscopy
  • This document does not address diagnostic nasopharyngoscopy.

Clinical Indications

Medically Necessary:

Diagnostic fiberoptic flexible laryngoscopy is considered medically necessary when ALL of the following are met:

  1. Larynx, pharynx, and related structures are not adequately visualized by the transoral mirror;
    and
  2. Any of the following indications apply:
    1. Diagnosis of symptomatic disorders involving the voice, swallowing, and upper aerodigestive tract, including obstructive sleep disorders; or
    2. Preoperative evaluation of vocal cord function for individuals undergoing surgery where the recurrent laryngeal or vagus nerves are at risk of injury (for example, thyroid, anterior cervical spine or carotid procedures); or
    3. Further evaluation of abnormalities of the upper aerodigestive tract discovered by another modality, such as CT, MRI, bronchoscopy or EGD.

A repeat diagnostic fiberoptic flexible laryngoscopy is considered medically necessary for any of the following indications:

  1. Assessing results of treatment for disorders involving the voice, swallowing, and upper aerodigestive tract, including obstructive sleep disorders; or
  2. Surveillance for recurrence of tumors of the upper aerodigestive tract; or
  3. Monitoring for growth or change of known lesions or disorders of the upper aerodigestive tract; or
  4. Postoperative evaluation of vocal cord function for individuals undergoing surgery where such function may be impacted, such as thyroid, anterior cervical spine or carotid procedures.

Not Medically Necessary:

Fiberoptic flexible laryngoscopy is considered not medically necessary when the criteria are not met.