CAM 60115

Videofluoroscopic Evaluation of Velopharyngeal Dysfunction

Category:Radiology   Last Reviewed:August 2019
Department(s):Medical Affairs   Next Review:August 2999
Original Date:July 1996    

Description:
Velopharyngeal dysfunction (VPD) refers to excessive nasal resonance or hypernasality during speech as the consequence of anatomical abnormalities of the velopharyngeal sphincter involving the velum (soft palate) and/or pharyngeal walls that compromise the seal between the nasopharynx and oral cavity. Normal phonation requires the generation of a column of air that flows from the subglottis into the upper airway. When (VPD) is present, air escapes through the nose during speech, resulting in the characteristic nasal resonancy. VPDis most commonly associated with cleft palate. It may be the only sign of a submucous cleft palate, or may persist after closure of an overt cleft palate.

Velopharyngeal dysfunction can usually be diagnosed by the speech/language pathologist based on the presence of hypernasal speech, compensatory misarticulations, escape of air through the nose, insufficient oral pressure for consonant production and aberrant facial movements. Imaging options include fiberoptic nasoendoscopy and videofluoroscopy.

Videofluoroscopy is a noninvasive radiologic technique intended to assess the competency of velopharyngeal closure. Videotape recording produces a continuous record of the velopharyngeal mechanism. A barium coating of the pharyngeal structures can be used to provide contrast in the videofluoroscopic image. Frontal and basal viewing angles can be used alone or in combination. The procedure is used to assess various forms of velopharyngeal insufficiency, including cleft palate. Videofluoroscopy is frequently performed as an adjunct to surgical planning in patients who do not respond to conservative treatment such as speech therapy.

Videostroboscopy provides detection of vibratory asymmetries, structural abnormalities, small masses, submucosal scars and other conditions that might not be visible under continuous light. It provides not only valuable information concerning the motion of the normal vocal cord movements. In contrast, stroboscopic examination revealed that half of the same patients had reduced mobility. A careful videostroboscopic examination can differentiate, to a certain extent, epithelial hyperplasia and dysplasia from invasive carcinoma of the vocal cords. Videostroboscopy is also useful for evaluating patients with vocal cord paralysis.

Policy:
Based on a strict evidence-based approach, videofluoroscopic evaluation is considered INVESTIGATIONAL as a technique to assist in surgical planning for treatment of velopharyngeal insufficiency. (CPT codes 70370 and 70371)

RATIONALE:
Evaluation of a diagnostic technology typically involves a 3-pronged approach, i.e., determining the technical feasibility of the test, its diagnostic parameters (i.e., sensitivity, specificity, positive and negative predictive value) compared to a gold standard, and whether or not management based on the results of the diagnostic test is associated with an improved health outcome. In the absence of a gold standard, it is particularly important to determine that the diagnostic test ultimately results in an improved health outcome.

Videofluoroscopy of velopharyngeal closure has been performed for many years, and in many articles and textbooks, it is identified as a standard component of surgical planning for velopharyngeal insufficiency. In 1988, an international working group established a system for quantifying, recording and describing movements of the relevant anatomy. A recommendation was also made that suggested that all patients with velopharyngeal deficiency be studied with both videofluoroscopy and nasopharnygoscopy (1), and the Ad Hoc Committee of the American Cleft Palate-Craniofacial Association suggests videofluoroscopy as one technique that may be helpful in evaluating velopharyngeal insufficiency. (2) For example, it is thought that defining the velopharyngeal closure pattern is particularly important to determine the appropriate surgical intervention. The 3 most common surgical approaches to velopharyngeal dysfunction include pharyngoplasty, pharyngeal flap or posterior wall augmentation. However, even within these broad categories of surgical approaches, the results of videofluoroscopy have been used to tailor the surgery to the individual patient. (3) Therefore, it is not surprising that a search of the literature did not identify any controlled studies that were specifically designed to investigate the role of videofluoroscopy in surgical planning. In addition, pre- and postsurgery videofluoroscopy would be ideally necessary to compare clinical assessments of speech and anatomic function. Postoperative studies are not routinely performed. In the future, MRI may replace videofluoroscopy. (4,5)

References:

  1. Golding-Kushner KF, Argamaso RV, Cotton RT et al. Standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy: a report from an international working group. Cleft Palate J 1990; 27(4):337-48.
  2. Dalston RM, Marsh JL, Vig KW et al. Minimal standards for reporting the results of surgery on patients with cleft lip, cleft palate or both: a proposal. Cleft Palate J 1998; 25(1):3-7.
  3. Ysunza A, Pamplona C, Ramirez E et al. Velopharyngeal surgery: a prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties. Plast Reconstr Surg 2002; 110(6):1401-7.
  4. Vadodaria S, Goodacre TE, Anslow P. Does MRI contribute to the investigation of palatal function? Br J Plast Surg 2000; 53(3):191-9.
  5. Witt PD, Marsh JL, McFarland EG et al. The evolution of velopharyngeal imaging. Ann Plast Surg 2000; 45(6):665-73.
  6. Singh A, Kazi R, Venkitaraman R, et al. Does flexible videostroboscopy compare with rigid videostroboscopy in the assessment of the neoglottis? A preliminary report. Clin Otolaryngol. 2008;33(1):60-63.
  7. Grøntved AM, Faber CE, Jakobsen J. Assessment of thyroplasty for vocal fold paralysis. Ugeskr Laeger. 2009;171(3):117-121.
  8. Kazi R, Rhys-Evans P, Nutting CM, Harrington KJ. The great debate: Stroboscopy vs high-speed imaging for assessment of alaryngeal phonation. J Cancer Res Ther. 2009;5(2):121-123.
  9. Verikas A, Uloza V, Bacauskiene M, et al. Advances in laryngeal imaging. Eur Arch Otorhinolaryngol. 2009;266(10):1509-1520

Coding Section

Codes Number Description
CPT 70370 Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique
  70371 Complex dynamic pharyngeal and speech evaluation by cine or video recording
ICD-9 Procedure 87.06 Contrast radiogram of nasopharynx
  87.09 Other soft tissue X-ray of face, head and neck (noncontrast)
ICD-9 Diagnosis 749 Cleft palate and cleft lip, code range
HCPCS   No Code
ICD-10-CM (effective 10/01/15)  Q35.9-Q37.9  Cleft palate and cleft lip, code range 
ICD-10-PCS (effective 10/01/15)  B91GYZZ  Fluoroscopy of Pharynx and Epiglottis using Other Contrast 
  B9040ZZ  Plain Radiography of Right Parotid Gland using High Osmolar Contrast 
  B9041ZZ  Plain Radiography of Right Parotid Gland using Low Osmolar Contrast 
  B904YZZ  Plain Radiography of Right Parotid Gland using Other Contrast 
  B9050ZZ  Plain Radiography of Left Parotid Gland using High Osmolar Contrast 
  B9051ZZ  Plain Radiography of Left Parotid Gland using Low Osmolar Contrast 
  B905YZZ  Plain Radiography of Left Parotid Gland using Other Contrast 
  B9060ZZ  Plain Radiography of Bilateral Parotid Glands using High Osmolar Contrast 
  B9061ZZ  Plain Radiography of Bilateral Parotid Glands using Low Osmolar Contrast 
  B906YZZ  Plain Radiography of Bilateral Parotid Glands using Other Contrast
  B9070ZZ  Plain Radiography of Right Submandibular Gland using High Osmolar 
  B9071ZZ  Plain Radiography of Right Submandibular Gland using Low Osmolar 
  B907YZZ  Plain Radiography of Right Submandibular Gland using Other Contrast 
  B9080ZZ  Plain Radiography of Left Submandibular Gland using High Osmolar Contrast 
  B9081ZZ 

Plain Radiography of Left Submandibular Gland using Low Osmolar Contrast 

  B908YZZ  Plain Radiography of Left Submandibular Gland using Other Contrast 
  B9090ZZ  Plain Radiography of Bilateral Submandibular Glands using High Osmolar Contrast 
  B9091ZZ  Plain Radiography of Bilateral Submandibular Glands using Low Osmolar Contrast 
  B909YZZ  Plain Radiography of Bilateral Submandibular Glands using Other Contrast 
  B90B0ZZ  Plain Radiography of Right Salivary Gland using High Osmolar Contrast 
  B90B1ZZ  Plain Radiography of Right Salivary Gland using Low Osmolar Contrast 
  B90BYZZ  Plain Radiography of Right Salivary Gland using Other Contrast 
  B90C0ZZ  Plain Radiography of Left Salivary Gland using High Osmolar Contrast 
  B90C1ZZ  Plain Radiography of Left Salivary Gland using Low Osmolar Contrast 
  B90CYZZ  Plain Radiography of Left Salivary Gland using Other Contrast 
  B90D0ZZ  Plain Radiography of Bilateral Salivary Glands using High Osmolar Contrast 
  B90D1ZZ Plain Radiography of Bilateral Salivary Glands using Low Osmolar Contrast
  B90DYZZ Plain Radiography of Bilateral Salivary Glands using Other Contrast
  B90FZZZ Plain Radiography of Nasopharynx/Oropharynx
  B91GZZZ Fluoroscopy of Pharynx and Epiglottis
  B91JZZZ Fluoroscopy of Larynx
  BB0DZZZ Plain Radiography of Upper Airways
  BD11ZZZ Fluoroscopy of Esophagus
  BD1BYZZ Fluoroscopy of Mouth/Oropharynx using Other Contrast
  BD1BZZZ Fluoroscopy of Mouth/Oropharynx
  BW190ZZ  Fluoroscopy of Head and Neck using High Osmolar Contrast 
  BW191ZZ  Fluoroscopy of Head and Neck using Low Osmolar Contrast 
  BW19YZZ Fluoroscopy of Head and Neck using Other Contrast
  BW19ZZZ Fluoroscopy of Head and Neck
Type of Service  Radiology   
Place of Service Outpatient   

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 and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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

History From 2014 Forward     

08/07/2019 

Annual review, no change to policy intent. 

08/28/2018 

Annual review, no change to policy intent. 

08/23/2017 

Annual Review. No change in policy intent. 

08/09/2016

Annual review, no change to policy intent. 

08/11/2015 

Annual review, no change to policy intent. Added coding. 

08/11/2014

Annual review, no changes made.


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