priority health thyroid procedures Prior Auth

Coverage Criteria

Screening for thyroid cancer

Not covered

Screening for thyroid cancer in asymptomatic adults is considered NOT medically necessary (USPSTF recommends against screening for thyroid cancer in asymptomatic adults).

Thyroid ultrasound (US)

Covered when ANY of the following are met

Thyroid ultrasound indications: 1) Patient has one or more clinical risk factors for thyroid cancer (examples: history of exposure to ionizing radiation to the head/neck, family history of thyroid disease or multiple endocrine neoplasia (MEN), known RET gene mutation, history of goiter). 2) A thyroid nodule is known or suspected on physical exam. 3) For an incidental thyroid nodule (ITN) identified on imaging, ultrasound is covered only when the American College of Radiology (ACR) criteria are met.

Examples provided in policy

Thyroid fine needle aspiration (FNA)

Covered when ALL of the following are met

Thyroid fine needle aspiration (FNA) with cytopathology is medically necessary only when the preceding thyroid ultrasound meets the criteria from at least one of the following guidelines: ACR TI-RADS, NCCN Thyroid Carcinoma guidelines, or ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer.

References: ACR TI-RADS (Tessler 2018), NCCN, ATA (Haugen 2015)

Thyroid molecular diagnostic tests

Covered when guideline criteria are met

Thyroid molecular diagnostic tests (e.g., Afirma, ThyroSeq, ThyGeNEXT, ThyraMIR) are considered medically necessary when the criteria in the applicable eviCore Lab Management Guideline are met; these specific test codes are managed by eviCore and require prior authorization.

Access eviCore guidelines via Priority Health Prism Authorization Criteria Lookup

Thyroidectomy (partial, total, subtotal)

Covered when InterQual criteria are met

Thyroidectomy: Partial, total, subtotal, or complete thyroidectomy is medically necessary when the applicable InterQual® Procedures criteria are met (adult or pediatric versions).

Access InterQual via Priority Health Prism Authorization Criteria Lookup

Radiofrequency Ablation of Benign Thyroid Nodules

Covered when ALL of the following are met

RFA of benign thyroid nodules: 1) The thyroid nodule has been demonstrated to be benign and is causing compressive symptoms (examples: dysphagia, neck fullness/pressure, hoarseness, shortness of breath). 2) Treatment is limited to one radiofrequency ablation (RFA) per benign nodule per year (policy specifies one RFA per nodule per year as medically necessary when compressive symptoms are present).one RFA per benign nodule per year

RFA is an outpatient ultrasound-guided thermal ablation procedure

Prior Authorization

Prior authorization is required for the following procedures and molecular tests

PA required list: Provider must obtain prior authorization before the service for any listed CPT/HCPCS procedure or molecular diagnostic test code (includes thyroidectomy procedure codes, radiofrequency ablation codes 60660/60661, and eviCore-managed molecular test codes).

Molecular diagnostic tests are managed by eviCore per policy guidance; access criteria via Priority Health Prism Authorization Criteria Lookup

Not Covered Procedures

Not covered

Explicit not-covered: Procedure coded 0673T (percutaneous laser ablation of benign thyroid nodules, including imaging guidance) is not covered.

Screening thyroid ultrasound for asymptomatic adults is excluded. Consistent with the USPSTF recommendation, screening for thyroid cancer in asymptomatic adults is considered NOT medically necessary; routine ultrasound solely for screening in individuals without signs, symptoms, or risk factors is not a covered benefit.

Percutaneous laser ablation for benign thyroid nodules coded as 0673T is explicitly not covered. Procedures billed with this code for percutaneous laser ablation, including imaging guidance, are excluded from coverage.

Screening for thyroid cancer in asymptomatic adults is considered NOT medically necessary per the United States Preventive Services Task Force (USPSTF). Ultrasound and related diagnostic services performed solely for population screening in asymptomatic individuals do not meet medical necessity criteria.

Experimental, investigational, or unproven treatments are excluded from coverage unless an individual case review with prior plan approval is obtained. Requests for such treatments require prior plan approval and will be adjudicated by a Priority Health medical director or clinical pharmacist; exceptions may be considered for terminal illness or severe, rapidly deteriorating conditions.

Coding & Procedure Codes

No prior authorization requiredCPT | mixed

10021	Fine needle aspiration; without imaging guidance
10005	Fine needle aspiration biopsy, including ultrasound guidance; first lesion
10006	Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure)
60100	Biopsy thyroid, percutaneous core needle
76536	Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation
78013	Thyroid imaging (including vascular flow, when performed)
78014	Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)
78015	Thyroid carcinoma metastases imaging; limited area (e.g., neck and chest only)
78016	Thyroid carcinoma metastases imaging; with additional studies (e.g., urinary recovery)
78018	Thyroid carcinoma metastases imaging; whole body

1–10 of 11

1/2

Prior authorization requiredCPT | HCPCS | mixed

60210	Partial thyroid lobectomy, unilateral; with or without isthmusectomy
60212	Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy
60220	Total thyroid lobectomy, unilateral; with or without isthmusectomy
60225	Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy
60240	Thyroidectomy, total or complete
60252	Thyroidectomy, total or subtotal for malignancy; with limited neck dissection
60254	Thyroidectomy, total or subtotal for malignancy; with radical neck dissection
60260	Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid
60270	Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach
60271	Thyroidectomy, including substernal thyroid; cervical approach

1–10 of 13

1/2

Thyroid molecular diagnostic tests (PA required, managed by Evicore)CPT | HCPCS | NDC | mixed

81546	Afirma Genomic Sequencing Classifier — mRNA gene expression analysis of FNA
0026U	ThyroSeq Genomic Classifier — DNA and mRNA NGS of 112 genes from FNA
0287U	ThyroSeq CRC — DNA and mRNA NGS of 112 genes from FNA or FFPE, predicting recurrence risk
0245U	ThyGeNEXT Thyroid Oncogene Panel — mutation and fusion analysis with associated risk of malignancy (from FNA)
0018U	ThyraMIR miRNA Gene Expression Classifier — microRNA profiling by RT-PCR from FNA

Prior Authorization Required CPT/HCPCSCPTCovered

60210	Partial thyroid lobectomy, unilateral; with or without isthmusectomy
60212	Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy
60220	Total thyroid lobectomy, unilateral; with or without isthmusectomy
60225	Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy
60240	Thyroidectomy, total or complete
60252	Thyroidectomy, total or subtotal for malignancy; with limited neck dissection
60254	Thyroidectomy, total or subtotal for malignancy; with radical neck dissection
60260	Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid
60270	Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach
60271	Thyroidectomy, including substernal thyroid; cervical approach

1–10 of 13

1/2

Molecular diagnostic tests (managed by eviCore)CPT | HCPCS | mixed

81546	Afirma Genomic Sequencing Classifier (mRNA gene expression analysis from FNA)
0026U	ThyroSeq Genomic Classifier (DNA and mRNA NGS from FNA)
0287U	ThyroSeq CRC (DNA and mRNA NGS from FNA or FFPE tissue for recurrence risk)
0245U	ThyGeNEXT Thyroid Oncogene Panel (mutation and fusion panel from FNA)
0018U	ThyraMIR miRNA Gene Expression Classifier (miRNA profiling from FNA)

Not CoveredCPTNot Covered

0673T

Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance.

ACR TI-RADS / Imaging thresholds

Required imaging standardsThyroid ultrasound and indications for fine-needle aspiration (FNA) must meet criteria from at least one of the following: ACR TI-RADS, NCCN Thyroid Carcinoma guidelines, or ATA Management Guidelines.

ACR TI-RADS for incidental nodulesFor incidental thyroid nodules (ITNs) identified on non-thyroid imaging, a dedicated thyroid ultrasound is a covered benefit only when the ACR criteria are met.

FNA prerequisiteThyroid FNA with cytopathology is medically necessary only when the preceding thyroid ultrasound meets criteria from ACR TI-RADS, NCCN, or ATA guidelines.

Guideline referencesPolicy references: ACR TI-RADS (Tessler 2018 / ACR TI-RADS), NCCN Thyroid Carcinoma Guidelines, and ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Not applicable; treatment decisions do not follow a step-therapy sequence. Providers must follow guideline-based criteria (InterQual for thyroidectomy and Evicore Lab Management for molecular diagnostic tests) and submit prior authorization requests when required to demonstrate medical necessity per the Priority Health Provider Manual.

Prior authorization is required for listed thyroidectomy CPT codes, radiofrequency ablation (CPT 60660/60661), ASC-only thyroidectomy code C7555, and the thyroid molecular diagnostic tests managed by Evicore (e.g., 81546, 0026U, 0287U, 0245U, 0018U.

Documentation Required

Medical Necessity Documentation & Denial Risk

When prior authorization is required, providers must submit documentation demonstrating medical necessity. Requests for experimental, investigational, or unproven treatments require plan approval and will be reviewed by a Priority Health medical director or clinical pharmacist. Individual case review may allow coverage for investigational yet promising care if prior plan approval is obtained.

Background

Incidental thyroid nodules are common findings on imaging studies and often do not require immediate intervention. Use of a dedicated thyroid ultrasound and application of guideline-based selection criteria (for example, ACR TI‑RADS, NCCN, or ATA criteria) helps identify nodules requiring further evaluation and reduces unnecessary fine needle aspirations (FNAs). When FNAs are indicated and performed, cytopathology establishes a definitive diagnosis in most cases, while a minority remain indeterminate; molecular diagnostic testing can further reduce diagnostic surgeries.

Definitions

Incidental thyroid nodule (ITN) — definition

DefinitionAn incidental thyroid nodule (ITN) is a thyroid nodule identified by an imaging study that was not previously detected or suspected clinically.

Prevalence on imagingITNs are seen in 20%-67% of ultrasound studies, up to 25% of contrast-enhanced chest CTs, 16%-18% of CT/MR neck scans, and 1%-2% of 18FDG-PET scans.

Assessment guidanceDedicated thyroid ultrasound for ITNs should follow ACR-specific criteria for nodules found by each imaging modality.

Radiofrequency ablation (RFA) — definition

DefinitionRadiofrequency ablation (RFA) is hyperthermic ablation using high-frequency alternating electric current (approximately 200–1200 kHz) applied via an electrode inserted into the thyroid nodule under ultrasound guidance to induce coagulative necrosis.

Procedure characteristics

OpenPayer

THYROID-RELATED PROCEDURES

Coverage Criteria

Coding & Procedure Codes

Provider Actions & Requirements

Background

Definitions