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:

For those not adequately visualized by the transoral mirror, diagnostic fiberoptic flexible laryngoscopy is considered medically necessary for any of the following indications:

• Diagnosis of symptomatic disorders involving the voice, swallowing, and upper aerodigestive tract, including obstructive sleep disorders; or
• 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
• 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:

• Assessing results of treatment for disorders involving the voice, swallowing, and upper aerodigestive tract, including obstructive sleep disorders; or
• Surveillance for recurrence of tumors of the upper aerodigestive tract; or
• Monitoring for growth or change of known lesions or disorders of the upper aerodigestive tract, which may or may not be subject to treatment; or
• 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 or when a transoral mirror examination is sufficient.

Coding

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.

CPT
31575	Laryngoscopy, flexible; diagnostic
ICD-10 Diagnosis
	All diagnoses

Discussion/General Information

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 a 2017 retrospective review, Joliat and colleagues evaluated the incidence and risk factors of transient/permanent postoperative recurrent laryngeal nerve (RLN). 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.

Definitions

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 chords.

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).

References

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, 2016. Available at: http://www.entnet.org/?q=node/904. Accessed on July 7, 2017.
2. First Coast Service Options. Services. Diagnostic Laryngoscopy (L33903). Available at : https://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx Accessed on July 7, 2017.
3. NCCN Clinical Practice Guidelines in Oncology^® . ^© 2017 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on July 7, 2017.
   • Head and Neck Cancers (V.2.2017). Revised May 8, 2017.
   • Thyroid Cancer (V.2.2017). Revised May 17, 2017.
4. 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.

Websites for Additional Information

1. National Cancer Institute (NCI). Available at: https://www.cancer.gov/ . Accessed on July 6, 2017.
2. National Institutes of Health. U.S. National Library of Medicine. Laryngoscopy and nasolarynoscopy. Updated August 5, 2015. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/007507.htm . Accessed on July 7, 2017.
3. 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 July 7, 2017.

Index

Fiberoptic
Laryngeal
Nasopharyngeal 

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status	Date	Action
Reviewed	08/03/2017	Medical Policy & Technology Assessment Committee (MPTAC) review. Updated formatting in the clinical indications statement. Updated Discussion, Definition, References and Website sections.
New	11/03/2016	MPTAC review. Initial guideline development.