Diagnosis: Thyroid nodule Treatment: Radio Frequency Ablation (60699) The insurer denied the Radio Frequency Ablation (60699) The denial is overturned The patient is a female with a large left multinodular goiter and an enlarging dominant thyroid nodule requesting thermal ablation. She is status post an alcohol ablation and a thermal ablation. Four biopsies of the nodules were benign. Yes, the health plan should cover the Radio Frequency Ablation (60699). A search on PubMed.com finds many articles regarding the use of thermal ablation to treat thyroid nodules. A systematic review by Muhammad, found that ablative therapy was an effective and safe alternative to surgical resection for benign thyroid nodules. A systematic review by Chung, found that "RFA [radiofrequency ablation] was found to be safe for the treatment of benign thyroid nodules and recurrent thyroid cancers." A systematic review, by Trimboli, found that "both RFA [radiofrequency ablation] and laser ablation are able to obtain a significant volume reduction in BNFSTNs [benign non-functioning solid thryoid nodules]. A significant volume reduction is already evident at 6 months after thermal ablation and results are stable over the time." A randomized controlled trial by Jin, found that "Thyroid thermal ablation is superior to conventional thyroidectomy in terms of patients satisfaction, post-operative quality of life, and shorter hospital stay but takes longer to achieve BTNs [benign thyroid nodules] volume reduction. The complication rates between the two groups were similar." A review by Jasim, for the American Association of Clinical Endocrinology, found that "Surgery and radioiodine treatment remain the conventional and established treatments for nodular goiters. However, the new image-guided minimally invasive approaches appear safe and effective alternatives." Thermal ablation of thyroid nodules has been proven to be efficacious and could be useful in this patient. It is in accordance with generally accepted standards of medical care, clinically appropriate, not for convenience, and not more intensive than alternatives. The requested thermal ablation would be considered medically appropriate for this patient. Yes, the requested therapy is likely to be more beneficial for the enrollee than any available standard therapy.

Diagnosis: Thyroid nodule Treatment: Radio Frequency Ablation (60699) The insurer denied the Radio Frequency Ablation (60699) The denial is overturned The patient is a female with a left large multinodular goiter with ongoing enlargement complicated by neck compressive symptoms. Request for radio frequency ablation of the thyroid (60699) is under review. The prior request was denied as experimental/investigational. The physician is appealing this determination. Yes, the health plan should cover the requested radio frequency ablation of the thyroid (60699). A recent meta-analysis of radiofrequency ablation of benign thyroid nodules showed a statistically significant improvement with the use of radiofrequency ablation, including reduction in nodule size and improvement of both symptoms and cosmetic scores. In a randomized clinical trial, radiofrequency ablation was superior to laser ablation in nodule volume reduction [1]. The AACE (American Association of Clinical Endocrinologists)/ACE (American College of Endocrinology)/AME (Associazione Medici Endocrinologi) Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules support that radiofrequency ablation is a less expensive and less invasive alternative to thyroid surgery, without the risks of subsequent cutaneous scar or hypothyroidism, and support the use of radiofrequency ablation in patients with benign thyroid nodules who warrant treatment such as for cosmetic reasons or local symptoms. This patient has a large multinodular goiter which was causing compressive symptoms. The use of radiofrequency ablation in this clinical situation is supported by the peer-reviewed literature and is in accordance with generally accepted standards of medical practice, clinically appropriate, not for convenience, and was the most appropriate level of care. Therefore, the health plan should cover the proposed radio frequency ablation of the thyroid (60699). Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease. The alternative treatment would be thyroidectomy. The AACE (American Association of Clinical Endocrinologists)/ACE (American College of Endocrinology)/AME (Associazione Medici Endocrinologi) Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules support that radiofrequency ablation is a less expensive and less invasive alternative to thyroid surgery, without the risks of subsequent cutaneous scar or hypothyroidism. Therefore, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.

Diagnosis: Thyroid nodule. Treatment: Radio Frequency Ablation (60699). The insurer denied the Radio Frequency Ablation (60699). The denial is overturned. The patient is a female diagnosed with left thyroid nodule. This request is for Radio Frequency Ablation CPT (Current Procedural Terminology) 60699. As reported; she is status post retreatment ablation for a left large Mutlinodular goiter. She is doing well in post-procedure. She is without N/V (nausea/vomiting), uncontrolled pain or difficulty speaking or swallowing void and walking. She has a past medical history for Large Mutlinodular goiter status post alcohol ablation and RFA (radiofrequency ablation). Approximately several years prior, she was discovered to have left thyroid mass. Since then she has had four FNAs (fine needle aspirations), all of which were benign. Her thyroid function has remained normal. She returns for retreatment of the mass which is enlarged from even baseline. She reports compression symptoms in the neck. The patient's FT4 (free thyroxin) was 1.6 (0.9-1.7); TSH (thyroid stimulating hormone) was 0.7 (0.3-4.2). Yes, the health plan should cover the Radio Frequency Ablation (60699), as it was medically appropriate, as described below. Yes, the Radio Frequency Ablation (60699) is more beneficial. The standard of care for large or enlarging thyroid nodules that are causing symptoms is resection or radiofrequency ablation, assuming they are shown to be benign. Radiofrequency ablation carries less morbidity and mortality and is equally effective when compared to surgical resection [1-3]. The patient has large thyroid nodules that are causing symptoms. The patient's nodules have been determined to be benign. Radiofrequency ablation is consistent with generally accepted standards of medical practice. It is more beneficial than the alternative, which is surgical resection, and carries less morbidity.

1) Park HS, Baek JH, Park AW, Chung SR, Choi YJ, Lee JH. Thyroid Radiofrequency Ablation: Updates on Innovative Devices and Techniques. Korean J Radiol. 2017 Jul-Aug;18(4):615-623. doi: 10.3348/kjr.2017.18.4.615. Epub 2017 May 19. PMID: 28670156; PMCID: PMC5447637. 2) Muhammad H, Santhanam P, Russell JO. Radiofrequency ablation and thyroid nodules: updated systematic review. Endocrine. 2021 Jun;72(3):619-632. doi: 10.1007/s12020-020-02598-6. Epub 2021 Jan 15. PMID: 33449296. 3) Chung SR, Suh CH, Baek JH, Park HS, Choi YJ, Lee JH. Safety of radiofrequency ablation of benign thyroid nodules and recurrent thyroid cancers: a systematic review and meta-analysis. Int J Hyperthermia. 2017 Dec;33(8):920-930. doi: 10.1080/02656736.2017.1337936. Epub 2017 Jun 26. PMID: 28565997. 4) Trimboli P, Castellana M, Sconfienza LM, Virili C, Pescatori LC, Cesareo R, Giorgino F, Negro R, Giovanella L, Mauri G. Efficacy of thermal ablation in benign non-functioning solid thyroid nodule: A systematic review and meta-analysis. Endocrine. 2020 Jan;67(1):35-43. doi: 10.1007/s12020-019-02019-3. Epub 2019 Jul 20. PMID: 31327158. 5) Jin H, Lin W, Lu L, Cui M. Conventional thyroidectomy vs thyroid thermal ablation on postoperative quality of life and satisfaction for patients with benign thyroid nodules. Eur J Endocrinol. 2021 Jan;184(1):131-141. doi: 10.1530/EJE-20-0562. PMID: 33112273. 6) Jasim S, Patel KN, Randolph G, Adams S, Cesareo R, Condon E, Henrichsen T, Itani M, Papaleontiou M, Rangel L, Schmitz J, Stan MN. American Association of Clinical Endocrinology Disease State Clinical Review: The Clinical Utility of Minimally Invasive Interventional Procedures in the Management of Benign and Malignant Thyroid Lesions. Endocr Pract. 2022 Apr;28(4):433-448. doi: 10.1016/j.eprac.2022.02.011. PMID: 35396078. 7) Orloff LA, Noel JE, Stack BC Jr, Russell MD, Angelos P, Baek JH, Brumund KT, Chiang FY, Cunnane MB, Davies L, Frasoldati A, Feng AY, Hegedüs L, Iwata AJ, Kandil E, Kuo J, Lombardi C, Lupo M, Maia AL, McIver B, Na DG, Novizio R, Papini E, Patel KN, Rangel L, Russell JO, Shin J, Shindo M, Shonka DC Jr, Karcioglu AS, Sinclair C, Singer M, Spiezia S, Steck JH, Steward D, Tae K, Tolley N, Valcavi R, Tufano RP, Tuttle RM, Volpi E, Wu CW, Abdelhamid Ahmed AH, Randolph GW. Radiofrequency ablation and related ultrasound-guided ablation technologies for treatment of benign and malignant thyroid disease: An international multidisciplinary consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association. Head Neck. 2022 Mar;44(3):633-660. doi: 10.1002/hed.26960. Epub 2021 Dec 23. PMID: 34939714.

1) Cesareo R, Pacella CM, Pasqualini V, Campagna G, Iozzino M, Gallo A, Lauria Pantano A, Cianni R, Pedone C, Pozzilli P, Taffon C. Laser ablation versus radiofrequency ablation for benign non-functioning thyroid nodules: six-month results of a randomized, parallel, open-label, trial (LARA Trial). Thyroid. 2020 Jun 1;30(6):847-56. 2) Durante C, Grani G, Lamartina L, Filetti S, Mandel SJ, Cooper DS. The diagnosis and management of thyroid nodules: a review. Jama. 2018 Mar 6;319(9):914-24.

1) Cesareo, R., et al., Radiofrequency ablation for the management of thyroid nodules: A critical appraisal of the literature. Clin Endocrinol (Oxf), 2017. 87(6): p. 639-648. 2) Faggiano, A., et al., Thyroid nodules treated with percutaneous radiofrequency thermal ablation: a comparative study. J Clin Endocrinol Metab, 2012. 97(12): p. 4439-45. 3) Sung, J.Y., et al., Radiofrequency ablation for autonomously functioning thyroid nodules: a multicenter study. Thyroid, 2015. 25(1): p. 112-7.