Clinical UM Guideline

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.

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.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure code listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

FFL provides indirect fiberoptic visualization of the laryngopharyngeal anatomy. The flexible fiberoptic scope can be introduced via the nose or mouth. The procedure can be performed in the office setting and only requires local anesthetic to the site usually delivered by spray.

Examples of symptomatic disorders where FFL is useful for evaluation include but are not limited to:

• adult with persistent, unexplained earache or sore throat
• chronic cough
• dysphagia
• dysphonia
• dyspnea
• laryngeal injury
• obstructive sleep apnea or severe snoring
• stridor
• suspected neoplasm
• suspected foreign body
• suspected aspiration

In 2016, the American Head and Neck Society (AHNS) recommends flexible transnasal laryngoscopy as the optimal laryngeal examination technique in individuals undergoing thyroid and parathyroid surgery. The society noted:

Flexible transnasal laryngoscopy is the optimal method for laryngeal examination on the basis of widespread availability, patient tolerance, and assessment of both RLN (recurrent laryngeal nerve) and EBSLN (external branch of the superior laryngeal nerve) function.

In a 2017 retrospective review, Joliat and colleagues evaluated the incidence and risk factors of transient/permanent postoperative recurrent laryngeal nerve (RLN) injury. The authors noted that 15% of the individuals (11/76) were found to have other ear, nose or throat (ENT) problems such as laryngopharyngeal reflux, laryngitis, sinusitis, or laryngeal edema during the preoperative fiberoptic laryngoscopy. The authors noted these findings were consistent with the other studies and underscored the importance of preoperative evaluation prior to thyroid or parathyroid surgery.

Scientific studies addressing the benefits of diagnostic FFL are limited. In a review, Holsinger and colleagues (2008) discussed the techniques and indications for FFL and stated that: “Visualization of the larynx and pharynx is an essential part of a complete head and neck examination.” While some structures of the laryngopharyngeal area of the head and neck cannot be examined by direct visualization, FFL can diagnose a variety of acute/chronic and benign/malignant disorders and is well tolerated.

Aerodigestive tract: The organs and tissues which comprise the respiratory tract and upper portion of the digestive tract. This includes the lips, mouth, tongue, nose, throat, vocal cords, and part of the esophagus and windpipe.

Dysphagia: Difficulty with swallowing.

Dyspnea: Difficult or labored breathing; shortness of breath.

Larynx: A flexible segment of the respiratory tract connecting the pharynx to the trachea in the neck; also known as the voice box or vocal cords.

Pharynx: A tube extending from the back of the nasal passages and mouth to the esophagus that is the passage through which air passes to the larynx and food to the esophagus.

Stridor: A high-pitched, wheezing sound caused by disrupted airflow. Airflow is usually disrupted by a blockage in the larynx (voice box) or trachea (windpipe).

Peer Reviewed Publications:

1. Collins SR. Direct and indirect laryngoscopy: equipment and techniques. Respir Care. 2014; 59(6):850-862; discussion 862-864.
2. Holsinger FC, Kies MS, Weinstock YE, et al. Videos in clinical medicine. Examination of the larynx and pharynx. N Engl J Med. 2008; 358(3):e2.
3. Joliat GR, Guarnero V, Demartines N, et al. Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: incidence and postoperative evolution assessment. Medicine (Baltimore). 2017; 96(17):e6674.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Otolaryngology—Head and Neck Surgery. Position Statement: The Roles of Flexible Laryngoscopy Videostroboscopy: The Roles of Flexible Laryngoscopy Videostroboscopy in the Office Evaluation and Management of Patients with Otolaryngologic Disorders. Updated March 20, 2016. Available at: http://www.entnet.org/?q=node/904. Accessed on March 23, 2023.
2. NCCN Clinical Practice Guidelines in Oncology^®. ^©2022 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on March 23, 2023. 
   • Head and Neck Cancers (V1.2023). Revised December 20, 2022.
   • Thyroid Carcinoma (V3.2022). Revised November 1, 2022.
3. Sinclair CF, Bumpous JM, Haugen BR, et al. Laryngeal examination in thyroid and parathyroid surgery: an American Head and Neck Society consensus statement. Head Neck. 2016; 38(6):811-819.

1. National Cancer Institute (NCI). Available at: https://www.cancer.gov/. Accessed on March 23, 2023.
2. National Institutes of Health. U.S. National Library of Medicine. Laryngoscopy and nasolarynoscopy. Reviewed August 31, 2021. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/007507.htm. Accessed on March 23, 2023.

Fiberoptic
Laryngeal
Nasopharyngeal

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