Are diagnostic laryngoscopy, nasal endoscopy, fine needle aspiration biopsy, and nasopharyngoscopy medically necessary for a patient with a history of hyperparathyroidism, post-operative hypercalcemia, and previous parathyroidectomies?

Medical Necessity Assessment for Requested Procedures

Direct Answer

The requested diagnostic procedures (31575 x6, 31231 x6, 92511 x6, 10005,10006) are NOT medically necessary for this patient with recurrent hyperparathyroidism status post bilateral parathyroidectomies. The appropriate imaging for recurrent/persistent hyperparathyroidism consists of parathyroid-specific localization studies (ultrasound, sestamibi scanning, or 4D-CT), not repetitive laryngoscopy, nasal endoscopy, or nasopharyngoscopy procedures 1.

Clinical Context and Appropriate Evaluation

Patient Status

• This 61-year-old female has undergone two parathyroidectomies (right 1/31/25, left with hemithyroidectomy 10/24/25) with current PTH of 29 pg/mL (10/25/25) 1
• The PTH level of 29 pg/mL is actually LOW, not elevated, suggesting successful parathyroid removal or possible hypoparathyroidism, not persistent hyperparathyroidism requiring further localization 1
• The diagnosis listed is hypercalcemia, but no current calcium level is provided to confirm persistent disease 1

Guideline-Based Imaging for Recurrent/Persistent Hyperparathyroidism

When imaging IS indicated for recurrent/persistent hyperparathyroidism, the ACR Appropriateness Criteria specify:

• First-line imaging options include: ultrasound of parathyroid glands, sestamibi dual-phase scan with SPECT/CT, or CT neck without and with IV contrast (4D-CT) 1
• Preoperative imaging is essential in the reoperative setting to localize target parathyroid lesions and identify postoperative changes from previous explorations 1
• Ultrasound is specifically recommended as first-line in the reoperative setting, with sensitivity of 46-69% for persistent/recurrent disease 1

Fine Needle Aspiration Considerations

FNA with PTH washout (CPT 10005,10006) may be appropriate ONLY when:

• Noninvasive imaging identifies a suspicious lesion that requires confirmation before reoperation 2, 3
• Prior imaging studies are inconclusive or discordant 2, 4
• FNA has 95.6% sensitivity when a target lesion is identified and is safer than repeat exploration without localization 3, 4
• However, FNA requires a target lesion identified on imaging first—it is not a screening tool 3, 4

Why the Requested Procedures Are Not Indicated

Laryngoscopy/Endoscopy Procedures (31575 x6, 31231 x6, 92511 x6)

These procedures evaluate the upper airway and vocal cords, NOT parathyroid glands:

• Diagnostic laryngoscopy (31575) assesses vocal cord pathology, not parathyroid disease 1
• Nasal endoscopy (31231) and nasopharyngoscopy (92511) examine nasal passages and nasopharynx, which are anatomically separate from parathyroid glands 1
• Requesting 6 units of each procedure has no medical justification in hyperparathyroidism management 1
• These would only be indicated if the patient had concurrent laryngeal nerve injury from prior surgery (hoarseness, dysphagia) or unrelated sinonasal pathology—none documented 1

Lack of Clinical Indication for Reoperation

The current biochemical data does not support persistent hyperparathyroidism:

• PTH of 29 pg/mL is below the normal range (typically 10-65 pg/mL), suggesting possible hypoparathyroidism or hungry bone syndrome as documented 1
• No current calcium level provided to confirm hypercalcemia 1
• Imaging for parathyroid localization is only indicated when biochemical hyperparathyroidism is confirmed and surgery is planned 1

Appropriate Next Steps

If persistent hyperparathyroidism is suspected, the correct approach is:

1. Confirm biochemical diagnosis: Obtain current serum calcium, ionized calcium, and intact PTH levels 1
2. If PTH >65 pg/mL with hypercalcemia: Proceed with parathyroid-specific imaging (ultrasound, sestamibi SPECT/CT, or 4D-CT) 1
3. If imaging identifies a target lesion: Consider FNA with PTH washout for confirmation before third surgery 2, 3
4. Monitor for hungry bone syndrome: Given recent surgery (10/24/25) and low PTH, assess for hypocalcemia requiring calcium/vitamin D supplementation 1

Critical Pitfalls to Avoid

• Do not perform airway endoscopy procedures to evaluate parathyroid disease—they assess different anatomical structures 1
• Do not order FNA without first identifying a target lesion on imaging 2, 3
• Do not pursue parathyroid imaging when PTH is low or normal—this suggests successful treatment, not persistent disease 1
• Repetitive units (x6) of endoscopic procedures have no established role in hyperparathyroidism and represent inappropriate utilization 1