Clinical UM Guideline
|Subject:||Tonsillectomy for Children with or without Adenoidectomy|
|Guideline #:||CG-SURG-30||Current Effective Date:||05/19/2016|
|Status:||Revised||Last Review Date:||05/05/2016|
This document addresses tonsillectomy in children with or without adenoidectomy. This surgery has been widely accepted as a treatment method for children with recurrent throat infections, tonsil hypertrophy and sleep-disordered breathing (SDB), and obstructive sleep apnea (OSA).
Note: This document does not address adenoidectomy separate from tonsillectomy.
Note: For information relating to adenoidectomy separate from tonsillectomy, please see:
Tonsillectomy is considered medically necessary for individuals less than 18.0 years of age who meet one or more of the criteria below:
*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.
Not Medically Necessary:
Tonsillectomy is considered not medically necessary for children less than 18.0 years of age when the criteria above have not been met, and in all other circumstances.
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.
|42820||Tonsillectomy and adenoidectomy; younger than age 12|
|42821||Tonsillectomy and adenoidectomy; age 12 or over|
|42825||Tonsillectomy, primary or secondary, younger than age 12|
|42826||Tonsillectomy, primary or secondary, age 12 or over|
|0CTP0ZZ||Resection of tonsils, open approach|
|0CTPXZZ||Resection of tonsils, external approach|
Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than 15 years of age. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing (SDB). Indications for surgery include recurrent throat infections and SDB, both of which can substantially affect child health status and quality of life. Although there are benefits of tonsillectomy, complications of surgery may include throat pain, postoperative nausea and vomiting, delayed feeding, voice changes, hemorrhage, and rarely death.
The American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) has a clinical practice guideline addressing the use of tonsillectomy in children (Baugh, 2011). In this guideline, they recommend the following:
It should be noted that the AAO-HNS guideline states the following:
The guideline does not apply to tonsillotomy, intracapsular surgery, or other partial removal techniques of the tonsil because of the relatively sparse high quality published evidence on these techniques and limited long-term follow-up. Similarly, the guideline does not apply to populations of children excluded from most tonsillectomy research studies, including those with diabetes mellitus, cardiopulmonary disease, craniofacial disorders, congenital anomalies of the head and neck region, sickle cell disease, and other coagulopathies or immunodeficiency disorders.
These recommendations are widely accepted as the standard of care for this procedure in children and are supported by extensive clinical trial data (Blakley, 2009; Brietzke, 2006; Friedman, 2009; Garavello, 2009; Paradise, 2002; Stewart, 2005; Tauman, 2006; van Staaij, 2004).
The most frequent indication for tonsillectomy is recurrent throat infection. According to the AAO-HNS, a throat infection is defined as sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, which may or may not be culture positive for group A streptococcus. This includes strep throat infection and acute tonsillitis, pharyngitis, adenotonsillitis, or tonsillopharyngitis. The symptoms of a throat infection vary due to the root cause, but may include scratchy sensation in the throat; dry throat; white patches or pus on the tonsils; redness and inflammation of the larynx, pharynx, or tonsils; swollen or sore glands of the neck and jaw; and pain when swallowing or speaking. The treatment methods used to address throat infections will depend upon the cause of the infection, but medications such as antibiotics and anti-inflammatory drugs to treat infection and alleviate symptoms are common. When an individual has frequent throat infections despite optimal treatment, the use of surgical interventions such as tonsillectomy may be warranted.
SDB is the second most common indication for tonsillectomy 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, the use of snoring as a criterion for 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. 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 under 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 tonsillectomy 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 tonsillar hypertrophy.
OSA is a major subset of SDB. Individuals with OSA suffer from redundant soft tissue in the pharynx, including the adenoids and tonsils, which block 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 Apnea-Hypopnea Index (AHI) is an indication of OSA (Au, 2009; Chan, 2004; Spruyt, 2012). Both the American Academy of Pediatrics (AAP) and AAO-HNS regard tonsillectomy as a reasonable option for any child with documented OSA.
In 2013, Marcus et al. published a single-blind randomized controlled trial (RCT) involving 464 children, 5 to 9 years of age, with OSA, 400 of whom completed the trial (86%). Subjects were randomized to either watchful-waiting (n=203) or early adenotonsillectomy (n=194) and followed for 7 months after randomization. The primary outcome, the attention and executive function score on the Developmental Neuropsychological Assessment, did not differ significantly at follow-up (p=0.16). However, the authors reported that there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group vs. the watchful-waiting group. Furthermore, normalization of polysomnographic findings was observed in a larger proportion of subjects in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). They conclude that their findings provide evidence of beneficial effects of early adenotonsillectomy.
Adenitis: A general term for an inflammation of a gland or lymph node.
Adenoids: Organs of the lymphatic system located in the nasal cavity above the roof of the mouth. The purpose of the adenoids is to capture germs entering the body through the mouth and nose.
Aphthous stomatitis: The medical term for "canker sores."
Cervical adenopathy: Enlargement of the cervical lymph nodes, located on both sides of the neck.
Group A β-hemolytic streptococcus (GABHS): A bacteria commonly associated with serious throat infections in children.
Pharyngitis: The medical term for a "sore throat."
PFAPA: A medical condition characterized by recurrent episodes of periodic fever, aphthous stomatitis, pharyngitis, and adenitis.
Obstructive sleep apnea: A condition which is characterized by cessation of breathing during sleep, caused by temporary collapse of the upper airway.
Polysomnography: Also known as a "sleep study." A test used to diagnose sleep disorders.
Sleep-disordered breathing (SDB): A group of disorders characterized by abnormalities of breathing pattern or the quantity of breathing during sleep.
Tonsils: Organs of the lymphatic system located at the back of the throat. The purpose of the tonsils is to capture germs entering the body through the mouth and nose.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Obstructive sleep apnea
Sleep disordered breathing
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Revised||05/25/2016||Clarified MN criteria C regarding sleep disordered breathing criteria to indicate that documentation of tonsillar hypertrophy and either of the conditions in the two sub-bullets is required.|
|Revised||05/05/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified MN criteria regarding sleep disordered breathing criteria. Updated Reference section.|
|Reviewed||11/05/2015||MPTAC review. Updated Reference section. Removed ICD-9 codes from Coding section.|
|Reviewed||11/13/2014||MPTAC review. Updated title to include "with or without Adenoidectomy". Updated Discussion and Reference sections.|
|Reviewed||11/14/2013||MPTAC review. Updated Discussion and Reference sections.|
|Revised||11/08/2012||MPTAC review. Added additional criteria for the diagnosis for sleep disordered breathing. Added medically necessary criteria for obstructive sleep apnea. Added medically necessary criteria for the diagnosis of SDB in children less than 3 years. Updated Discussion, Definitions and Reference sections.|
|Revised||08/09/2012||MPTAC review. Clarified age criteria in the position statement.|
|New||02/16/2012||MPTAC review. Initial document development.|