Diagnosis: Neck Mass

Treatment: Computed Tomography Scan of the neck

The insurer denied coverage for Computed Tomography Scan of the neck. The denial is reversed.

This patient is a male who presented to the physician's office with a right lateral neck mass that was noted five days prior to presentation. The mass was large, hard to palpation, and non-tender without drainage. There was no skin changes noted. The patient denied fever, chills, and had no weight loss. The patient reported chronic congestion for a few months. The patient had nonallergic rhinitis and asthma. The patient had no sinus pain or ear pain. The physical examination revealed lymphadenopathy in the right lateral neck with a 1.5 cm hard, well-circumscribed, non-mobile mass. The diagnosis was localized mass of the neck. The treatment plan included computed tomography of the neck soft tissue with and without contrast. The insurer denied the computed tomography.

According to the clinical guideline referenced below "STATEMENT 6. IMAGING: Clinicians should order a neck computed tomography (CT; or magnetic resonance imaging [MRI]) with contrast for patients with a neck mass deemed at increased risk for malignancy. Strong recommendation based on randomized controlled trials." In this case, this male with a history of fatigue and decreased libido for months who presented with a firm, large, non-tender mass in his neck. This would be highly suspicious for malignancy, which would be a strong indication for a CT scan of the neck. This reviewer approves this radiological study.

The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The Computed Tomography Scan of the neck performed is medically necessary for this patient.

The carrier's denial of coverage for the Computed Tomography Scan of the neck performed is reversed. The medical necessity is substantiated.