Description

The thyroid is a butterfly-shaped gland located in the front of the neck just below the larynx (voice box). The thyroid makes specific hormones that are secreted into the blood and then carried to other tissues in the body. Thyroid hormones help the body use energy, stay warm and keep organs working properly. The term thyroid nodule refers to an abnormal growth of cells that form a lump within the thyroid gland. Although many thyroid nodules are benign (noncancerous), a small proportion of thyroid nodules may be malignant (cancerous).

Evaluation

Once a nodule is discovered, further evaluation is necessary to learn if the rest of the thyroid is healthy or if the entire thyroid gland has been affected by a cancer, or a noncancerous condition such as hyper or hypothyroidism. During a physical exam, the gland will be assessed for enlargement as well as the presence of nodules (single or multiple). Initial laboratory tests may include measurement of thyroid hormone (thyroxine or T4) and thyroid-stimulating hormone (TSH) in the blood to determine how the thyroid is functioning.

Since it is not always possible to determine whether a thyroid nodule is cancerous by physical examination and blood tests alone, the evaluation of the thyroid nodules will often include specialized tests which may include:

• Thyroid ultrasound uses high frequency sound waves to obtain a picture of the thyroid. This test can determine characteristics or precise size of a nodule and identify nodules too small to be felt during a physical examination. Ultrasound can also be used to accurately guide a needle directly into a nodule when a fine needle biopsy is warranted.
• Fine needle aspiration biopsy (FNA or FNAB) is a procedure where a thin needle is inserted into the nodule to withdraw cells for examination. Ordinarily, several samples will be taken from different parts of the nodule to provide the best chance of finding cancerous cells, if they are present. The cells are then examined under a microscope by a pathologist. The report of a thyroid fine needle biopsy will usually indicate that the nodule is in one of six categories according to the Bethesda Classification System.

Laboratory examination of cells in thyroid nodules acquired through FNA has been proposed to assist in exploring the possibility of thyroid cancer. These tests are used to detect molecular markers that are associated with thyroid cancer and are performed when cytopathology cannot determine if the nodule is malignant or benign. For information regarding molecular testing of thyroid nodules, please refer to Molecular Markers in Fine Needle Aspirates of Thyroid Nodules Medical Coverage Policy.

Surgical Treatment

Thyroid nodules that are found to be benign by initial FNA or which are too small to biopsy, are monitored closely via physical exam and repeated ultrasound or FNA.

Surgery may still be recommended even for a nodule that is benign if it has diffuse enlargement or causes compression symptoms.

Thyroid Surgeries (Thyroidectomy & Lobectomy)

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0566-006

Page: 3 of 12

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Thyroid nodules that are malignant, or that are highly suspicious of cancer, typically require surgery. The extent of the surgery performed depends on a multitude of variables; some of these include cancer type, size and location of nodule(s), symptoms, individual’s age and/or preference. Thyroid surgeries include, but are not limited to:

• Lobectomy (or hemi-thyroidectomy) – Procedure where one lobe (one half) of the thyroid is removed
• Thyroidectomy (total or near-total) – Procedure where all or most of the thyroid tissue is removed

For information regarding intraoperative neurological monitoring during thyroid surgery, please refer to Intraoperative Neurological Monitoring Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for thyroid lobectomy or thyroidectomy when the following criteria are met:

• Diffuse enlargement of the thyroid gland (eg, goiter); OR
• Nodule(s) causing compressive symptoms (eg, choking, dysphagia, dyspnea, hoarseness); OR
• Nodule(s) measuring greater than or equal to 4 cm; OR
• Nodule(s) measuring less than 4 cm with suspicious pattern identified on ultrasound; AND any of the following:

1. Documented contraindication to radioactive iodine therapy (eg, breastfeeding, child 4 years of age or younger, pregnancy); OR
2. FNA results are indeterminate or malignant (Bethesda III, IV, V or VI); OR
3. Results of molecular testing demonstrate suspicious pattern (for information regarding coverage determination/limitations, please refer to Molecular Markers in Fine Needle Aspirates of Thyroid Nodules Medical Coverage Policy); OR
4. Prior surgery of nodule(s) demonstrated malignancy and further removal is required based on pathology; OR
5. Prophylactic total thyroidectomy for asymptomatic child 5 years of age or younger with identified RET gene mutation (for information regarding coverage determination/limitations for MEN2 (RET sequencing), please refer to Genetic Testing for Cancer Susceptibility Medical Coverage Policy)

Coverage Limitations

Humana members may NOT be eligible under the Plan for thyroid lobectomy or thyroidectomy for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate.

Please refer to the member’s individual certificate for the specific definition.

Additional information about thyroid nodules may be found from the following websites:

• Background
• American Thyroid Association
• National Library of Medicine
• Medical Alternatives
• Alternatives to thyroid surgeries include, but may not be limited to, the following:
• Prescription drug therapy
• Radioactive iodine therapy
• Radiofrequency ablation (please refer to Radiofrequency Tumor Ablation Medical Coverage Policy)
• Watchful waiting (eg, observing for changes such as increase in size, worsening of symptoms or monitoring by repeat FNA or ultrasound)

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.