Clinical UM Guideline
|Guideline #:||CG-SURG-36||Current Effective Date:||01/13/2015|
|Status:||Reviewed||Last Review Date:||11/13/2014|
This document addresses the use of adenoidectomy, a surgical procedure to remove the adenoids, which are also known as pharyngeal tonsils or nasopharyngeal tonsils. Adenoidectomy is a common surgical procedure used to treat an array of conditions.
Note: This document only applies to adenoidectomy alone. If tonsillectomy is proposed in addition to adenoidectomy, please see:
Adenoidectomy is considered medically necessary for individuals under the age of 18 years old when any of the following conditions are met:
*Note: Documentation of SDB can be made on the basis of physical and history only, and does not require polysomnography. A history of snoring alone is not sufficient to make a diagnosis of SDB.
Adenoidectomy is also considered medically necessary for individuals of any age for suspected adenoid tumor based on imaging (for example, CT), nasopharnygoscopy or endoscopy.
Not Medically Necessary:
Adenoidectomy is considered not medically necessary for other indications and when criteria above are not met, including, but not limited to, use in children less than 4 years of age with acute or recurrent otitis media.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|42830||Adenoidectomy, primary; younger than age 12|
|42831||Adenoidectomy, primary; age 12 or over|
|42835||Adenoidectomy, secondary; younger than age 12|
|42836||Adenoidectomy, secondary; age 12 or over|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|28.6||Adenoidectomy without tonsillectomy|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Procedure||[For dates of service on or after 10/01/2015]|
|0CTQ0ZZ||Resection of adenoids, open approach|
|0CTQXZZ||Resection of adenoids, external approach|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
The adenoid, also known as a pharyngeal tonsil or nasopharyngeal tonsil, is a mass of lymphatic tissue situated at the back of the nasal cavity, in the roof of the nasopharynx, where the nose blends into the throat. It is a part of the lymphatic system, which plays a function in combating infections in the body. Additionally, the adenoids may also act as reservoirs for bacterial infections, contributing to recurrent infections of the sinuses, throat (pharyngitis), or middle ear.
Adenoids may become enlarged when actively involved in fighting an infection. Chronic enlargement, referred to as adenoid hypertrophy, can result from persistent infection and in an increase of the adenoids to the size of a ping pong ball. This enlargement may prevent airflow through the nasal passages, or obstruct airflow such that breathing through the nose requires excessive effort. This may contribute to obstructive sleep apnea (OSA).
Adenoidectomy has been widely accepted and proven to be an effective treatment for children with medically-refractory chronic adenoiditis with rhinorrhea or chronic rhinosinusitis, otitis media with effusion, and obstructive adenoid hypertrophy resulting in obstructive sleep apnea (Lieberthal, 2013; Marcus, 2012; Petcu, 2013).
The use of adenoidectomy for the treatment of otits media (OM), either acute or with effusion, has been a focus of investigation for many years. One area of concern is the use of this procedure, with or without the use of tympanostomy tubes, in the treatment of OM in children under 4 years of age. Several large, well-designed randomized controlled trials (RCTs) have been conducted, with the findings regarding benefit mixed between none and only small benefits reported. Of the studies reporting no benefit, the use of tympanostomy tubes was included in the study protocol (Casselbrant, 2009; Hammaren, 2005; Koivunen, 2004; Mattila, 2003). The studies that did report some benefit, tympanostomy tubes were used in two (Kujala, 2012; MRC, 2012), but not in a third (Paradise, 1999).
The American Academy of Pediatrics (AAP) guideline for the diagnosis and management of acute otitis media (Lieberthal, 2013) says: "Adenoidectomy alone should not be used for prevention of AOM but may have benefit when performed with placement of tympanostomy tubes or in children with previous tympanostomy tube placement in OME." Note that this statement is equivocal, in that they say it "may" be of benefit for AOM. However, the available data from RCTs does not support this statement at this time. Furthermore, the use of adenoidectomy is not recommended in the AAP's own Text Book of Pediatric Care (Petcu, 2013), which says:
Adenoidectomy (but not tonsillectomy) appears to be effective in decreasing the rate of PE tube (Pressure Equalization, or ventilation tube) reinsertion. Adenoidectomy has a limited role in treatment of chronic otitis media with effusion for children older than 4 years, particularly if nasal obstruction, recurrent sinusitis, or chronic sinusitis are present. Finally, adenoidectomy does not reduce the incidence of recurrent acute otitis media when performed in conjunction with insertion of PE tubes for children younger than 4 years.
In a clinical practice guideline for OM with effusion published jointly by the American Academy of Family Physicians (AFP), the American Academy of Otolaryngology- Head and Neck Surgery (AAO-HNS) and the AAP (Rosenfeld, 2004), it is recommended that adenoidectomy be used as a second line treatment. They state, "Tympanostomy tubes are recommended for initial surgery because randomized trials show a mean 62% relative decrease in effusion prevalence and an absolute decrease of 128 effusion days per child during the next year." They go on to detail the significant risks of adenoidectomy in comparison to tympanostomy and conclude, "Consequently, adenoidectomy is not recommended for initial OME surgery unless a distinct indication exists, such as adenoiditis, postnasal obstruction, or chronic sinusitis."
Thus, at this time the evidence is not supportive of the use of adenoidectomy with or without tympanostomy tubes, in children under the age of 4 years of age who have chronic OM with effusion or recurrent acute otitis media.
The use of adenoidectomy is widely accepted to be an effective treatment for suspected adenoid tumor. While there is little clinical trial evidence to support this procedure, the removal of malignant tissue is the standard of care in most head and neck cancers (NCCN, 2013).
Sleep disordered breathing (SDB) is a frequent indication for adenoidectomy in children and is characterized by disturbances in breathing pattern or efficacy during sleep. Unfortunately, there is no widely accepted standard for the diagnosis of SDB. However, it is recognized that SDB may involve snoring, mouth breathing, and pauses in breathing (apnea). However, use of snoring in the diagnosis of SDB should be used carefully, as the AAO-HNS states, "The presence or absence of snoring neither includes nor excludes SDB, as not all children who snore have SDB, and caregivers may not observe intermittent snoring that occurs during the night" (Baugh, 2011). Daytime symptoms associated with SDB may include excessive sleepiness, inattention, poor concentration, aggression, depression, hyperactivity, and wetting the bed. A wide array of obstructive disorders may result in SDB, ranging in severity from simple snoring to obstructive sleep apnea. The most common cause of SDB in children is tonsillar hypertrophy, which is an abnormal enlargement of the tonsils, including the adenoids. This may be due to chronic infection or excess tissue growth. Diagnosis of SDB may be based on an individual's medical history, physical examination, audio/video taping, pulse oximetry, or limited or full-night polysomnogram, also known as a sleep test. History and physical examination are the most common initial methods for diagnosis. Treatment may involve antibiotics to address underlying infection, but if such treatment fails or is not indicated, tonsillectomy may be warranted.
In children less than 3 years of age, behavioral issues related to SDB may be more difficult to identify (for example, they may not yet be continent and, as such, enuresis would not necessarily be a sign of SDB). In addition, access to diagnostic polysomnography may be difficult and the results may be less reliable. Based on additional clinical input from specialists in the field, it would be appropriate to consider adenoidectomy when a parent or caregiver reports regular episodes of nocturnal choking, gasping, apnea, or breath holding which have persisted for several months in the setting of documented adenoid hypertrophy.
Obstructive sleep apnea (OSA) is a major subset of SDB. Individuals with OSA suffer from redundant soft tissue in the pharynx, including the adenoids and tonsils, which blocks the upper airway leading to periodic cessation of breathing. Individuals with OSA must change sleep position or increase their respiratory effort to overcome the blockage, disrupting sleeping patterns. Symptoms of OSA may include nocturnal gasping, cyanosis, excessive daytime sleepiness, pulmonary hypertension, and snoring, to name just a few. The diagnosis of OSA in children has not been standardized, although there is some consensus that a threshold of greater than one on the AHI is an indication of OSA (Au 2009; Chan, 2004; Spruyt, 2012). Both the AAP and AAO-HNS regard adenoidectomy as a reasonable option for any child with documented OSA and adenoid hypertrophy (AAO-HNS, 2012; Marcus, 2012).
Acute otitis media (AOM): A middle ear infection characterized by the rapid onset of signs and symptoms of inflammation (for example, pain) in the middle ear.
Adenoidectomy: A surgical procedure to remove the adenoids.
Adenoiditis: A condition characterized by inflammation of the adenoids.
Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. An AHI/RDI greater than 30 is consistent with severe OSA. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation.
Myringotomy: A surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid, or to drain pus from the middle ear.
Nasopharyngoscopy: A diagnostic procedure that examines the nasal passageways and pharynx with an instrument fitted with an optical system.
Otitis media: The medical term for middle ear infection.
Otitis media with effusion (OME): A condition of the middle ear characterized by inflammation and fluid accumulation. The signs and symptoms of acute infection, such as acute pain, are absent.
Rhinorrhea: A condition where the nasal cavity is filled with a significant amount of mucous fluid; commonly known as "runny nose."
Rhinosinusitis: A condition characterized by inflammation of the nasal passages and sinus cavities. It is usually caused by allergies, autoimmune, or an infection. It causes a combination of symptoms of rhinitis and sinusitis, including runny nose, clogged nasal passages, and post-nasal drip.
Sleep-disordered breathing (SDB): A group of disorders characterized by abnormalities of breathing pattern or the quantity of breathing during sleep.
Tympanostomy tube (also known as a grommet, T-tube, ear tube, pressure equalization or PE tube, vent, PE tube or myringotomy tube): A small tube inserted into the eardrum during a myringotomy in order to keep the middle ear aerated for a prolonged period of time, and to prevent the accumulation of fluid in the middle ear.
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Government Agency, Medical Society, and Other Authoritative Publications:
|Reviewed||11/13/2014||Medical Policy and Technology Assessment Committee (MPTAC) review. No change to clinical indications. Updated Reference section.|
|New||11/14/2013||MPTAC review. Initial document development.|