Description
High resolution CT can visualize both normal and pathologic anatomy of the neck. It is used in the evaluation of neck soft tissue masses, abscesses, and lymphadenopathy. For neck tumors, it defines the extent of the primary tumor and identifies lymph node spread. CT provides details about the larynx and cervical trachea and its pathology. Additional information regarding airway pathology is provided by three-dimensional images created from the CT dataset. Neck CT can also accurately depict and characterize tracheal stenoses.

With the rise of human papillomavirus-related oral, pharyngeal, and laryngeal cancers in adults, contrast-enhanced neck CT has become more important for the evaluation of a neck mass, deemed at risk for malignancy, surpassing ultrasound for the initial evaluation in many cases.

The American Academy of Otolaryngology — Head and Neck Surgery recently issued strong recommendations for neck CT or MRI, emphasizing the importance of a timely diagnosis.⁵

GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy

INDICATIONS FOR NECK CT^1,2

Suspected tumor or cancer

• Suspicious lesions in mouth or throat³
• Suspicious mass/tumor found on another imaging study and needing clarification¹
• Neck mass or lymphadenopathy (not parotid region and not thyroid region):
  • Present on physical exam and remains non-diagnostic after ultrasound is completed³
  • Mass or abnormality found on other imaging study and needing further evaluation
  • Increased risk for malignancy4 with one or more of the following findings:⁵
    • Fixation to adjacent tissues
    • Firm consistency
    • Size > 1.5 cm
    • Ulceration of overlying skin
    • Mass present ≥ two weeks (or uncertain duration) without significant
    • fluctuation and not considered of infectious cause
    • History of cancer
  • Failed 2 weeks of treatment for suspected infectious adenopathy⁶
  • Pediatric (≤ 18 years old) considerations⁷
    • Ultrasound should be inconclusive or suspicious unless there is a history of malignancy⁸

Note: For discrete cystic lesions of the neck, an ultrasound should be performed as initial imaging unless there is a high suspicion of malignancy

• Neck Mass (parotid region)¹
  • Parotid mass found on other imaging study and needing further evaluation

Note: US is the initial imaging study of a parotid region mass to determine if the location is inside or outside the gland^1,9,10

• Neck Mass (thyroid region)²
  • Staging and monitoring for recurrence of known thyroid cancer²
  • To assess extent of thyroid tissue when other imaging suggests extension through the thoracic inlet into the mediastinum or concern for airway compression^11,12

Note: US is the initial imaging study of a thyroid region mass. Biopsy is usually the next step. In the evaluation of known thyroid malignancy, CT is preferred over MRI since there is less respiratory motion artifact. Chest CT may be included for preoperative assessment in some cases.

Known or suspected deep space infections or abscesses of the pharynx or neck with signs or symptoms of infection¹³

Known tumor or cancer of skull base, tongue, larynx, nasopharynx, pharynx, or salivary glands¹⁴

• Initial staging³
• Restaging during treatment
• Areas difficult to visualize on follow-up examination
• Suspected recurrence or metastases based on symptoms or examination findings¹⁵
  • New mass
  • Change in lymph nodes

Indication for combination studies for the initial pre-therapy staging of cancer, OR active monitoring for recurrence as clinically indicated OR evaluation of suspected metastases

• ≤ 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: neck, abdomen, pelvis, chest, brain, cervical spine, thoracic spine or lumbar spine

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation (e.g., post neck dissection)

• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Further evaluation of indeterminate findings on prior imaging (unless follow up is otherwise specified within the guideline):

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam)

Other indications for a neck CT

• Sialadenitis (infection and inflammation of the salivary glands) with indeterminate ultrasound, bilateral symptoms or concern for abscess¹⁶
• Suspected or known salivary gland stones^{10,16,17,18,19}
• To assess for foreign body when radiograph is inconclusive or negative²⁰
• Vocal cord lesions or vocal cord paralysis²¹
• For evaluation of tracheal stenosis^22,23
• Dysphagia after appropriate work up including endoscopy and fluoroscopic studies (modified barium swallow, or biphasic Esophogram)^24,25
• Unexplained throat pain for more than 2 weeks when ordered by a specialist with all of the following^26,27,28
  • Complete otolaryngologic exam and laryngoscopy
  • No signs of infection
  • Evaluation for and failed treatment of laryngopharyngeal reflux
  • Risk factor for malignancy, i.e., tobacco use, alcohol use, dysphagia, weight loss OR age older than 50 years
• Unexplained ear pain when ordered by a specialist and MRI is contraindicated with all of the following²⁹
  • Otoscopic exam, nasolaryngoscopy, lab evaluation (ESR, CBC) AND
  • Risk factor for malignancy, i.e., tobacco use, alcohol use, dysphagia, weight loss OR age older than 50 years
• Diagnosed primary hyperparathyroidism when surgery is planned³⁰
  • Previous nondiagnostic ultrasound or nuclear medicine scan³¹
  • Bell’s palsy/hemifacial spasm, if MRI is contraindicated or cannot be performed (for evaluation of the extracranial nerve course)
  • If atypical signs, slow resolution beyond three weeks, no improvement at four months, or facial twitching/spasms prior to onset³²
• Objective cranial nerve palsy (CN IX-XII) if MRI is contraindicated or cannot be performed (for evaluation of the extracranial nerve course)^33,34
   

References 

31. Tian Y, Tanny ST, Einsiedel P, et al. Four-Dimensional Computed Tomography: Clinical Impact for Patients with Primary Hyperparathyroidism. Ann Surg Oncol. Jan 2018;25(1):117- 121. doi:10.1245/s10434-017-6115-9
32. Quesnel AM, Lindsay RW, Hadlock TA. When the bell tolls on Bell's palsy: finding occult malignancy in acute-onset facial paralysis. Am J Otolaryngol. Sep-Oct 2010;31(5):339-42. doi:10.1016/j.amjoto.2009.04.003
33. Mumtaz S, Jensen MB. Facial neuropathy with imaging enhancement of the facial nerve: a case report. Future Neurol. Nov 1 2014;9(6):571-576. doi:10.2217/fnl.14.55
34. American College of Radiology. ACR Appropriateness Criteria® Cranial Neuropathy. American College of Radiology (ACR). Updated 2022. Accessed January 22, 2023. https://acsearch.acr.org/docs/69509/Narrative/

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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