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Videostroboscopy
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This policy governs when videostroboscopy is considered medically necessary or experimental for Aetna members, defining covered diagnostic indications and required prior examinations for vocal cord pathology evaluation.
No material clinical or coverage changes in this revision.
Coverage Criteria: When Videostroboscopy Is Considered Medically Necessary
Medical Necessity (Covered Indication)
Covered when ALL of the following are met
From policy scope requiring both prior exams before videostroboscopy
Policy specifies coverage when prior mirror-image and endoscopic exams are nondiagnostic despite ongoing symptoms
Covered diagnostic indications listed in policy
Aetna considers videostroboscopy experimental and investigational for all indications other than its specified diagnostic use following prior examinations. Coverage is limited to the scenario where the member has had both a mirror-image and an endoscopic examination and those examinations failed to identify abnormal function or clinical pathology despite persistent symptoms.
Any other use of videostroboscopy beyond the diagnostic indication described above is experimental and investigational because effectiveness for those indications has not been established.
Coding: CPT and ICD-10 References
| 31579 | Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy. |
| C32.0-C32.2 | Malignant neoplasm of glottis, supraglottis, subglottis [vocal cords]. |
| C78.39 | Secondary malignant neoplasm of other respiratory organs [invasive carcinoma vocal cords]. |
| D02.0 | Carcinoma in situ of larynx [vocal cords]. |
| D14.1 | Benign neoplasm of larynx [vocal cord]. |
| D38.0 | Neoplasm of uncertain behavior of larynx [vocal cords]. |
| D49.1 | Neoplasms of unspecified behavior of respiratory system [vocal cords]. |
| J38.00-J38.7 | Diseases of vocal cords and larynx, not elsewhere classified. |
Provider Actions and Documentation Requirements
Prior exam prerequisite for CPT 31579
Prior exam prerequisite for CPT 31579 — videostroboscopy (CPT 31579) is covered only when selection criteria are met, specifically after prior mirror-image and endoscopic examinations have been performed and no abnormality was found but symptoms persist.
- Affected CPT: 31579
Required prior examinations
Required prior examinations — providers must perform and document both a mirror-image (indirect laryngoscopy) and an endoscopic examination before videostroboscopy for the covered indication.
- Both mirror-image and endoscopic exams required and must be documented
Prerequisite examinations required
Prerequisite examinations required — videostroboscopy may be denied if documentation does not show that both mirror-image and endoscopic examinations were performed and that symptoms persist despite normal findings on those exams.
- Denial risk if prior exams not documented or if indication not met
Required clinical documentation
Required clinical documentation — clinical records should reflect prior mirror-image and endoscopic examinations, persistent symptoms despite normal findings on those exams, and notes about inability to perform prerequisite exams when applicable (for example, aphonia or inability to phonate).
- Document prior mirror-image and endoscopic exams and persistent symptoms
- If prerequisite exams could not be performed, document reason (e.g., aphonia, inability to phonate)
Prior authorization
Prior authorization — no prior authorization requirements are stated in this excerpt.
- No prior authorization requirement appears in this excerpt
Step therapy / other utilization management
Step therapy / other utilization management — no step therapy or step-wise treatment requirements are stated in this excerpt.
- No step therapy requirements in this excerpt
Supplementary denial/authorization note
Supplementary denial/authorization note — this excerpt contains only additional informational links and does not specify further denial criteria or authorization requirements.
- Excerpt contains only additional informational links; no further authorization/denial rules provided
Miscellaneous footer links and additional info
Miscellaneous footer links and additional info — the policy excerpt includes supplementary links and resources but does not change the documentation or coverage requirements stated above.
- Additional links (glossary, app, FAQs, legal notices) are informational only
Background
Videostroboscopy is a diagnostic laryngeal procedure that uses stroboscopic illumination combined with rigid or flexible laryngoscopy and video recording to assess vocal fold vibratory function. It is performed to detect vocal cord pathology such as polyps, small masses, submucosal scars, and to evaluate vocal cord paresis, paralysis, or early invasive carcinoma. The procedure requires the patient to phonate steadily while the clinician assesses vibratory asymmetries and other subtle abnormalities.
Definitions and Contraindications
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