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Clinical Policy Title: Tonsillectomy and (or) adenoidectomy in children up to 12

years old

Clinical Policy Number: 11.03.04

Effective Date: October 1, 2014

Initial Review Date: April 16, 2014

Most Recent Review Date: May 1, 2018

Next Review Date: May 2019

Related policies:

None.

ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies, along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.

Coverage policy

AmeriHealth Caritas considers the tonsillectomy and/or adenoidectomy to be clinically proven and,

therefore, medically necessary when the following criteria are met:

A history of recurrent throat infection with a frequency of at least:

o 7 episodes in the past year; or

o 5 episodes per year for 2 years; or

o 3 episodes per year for 3 years;

AND

o Documentation in the medical record for each episode of sore throat which includes at

least one of the following:

Temperature greater than 38.3 °C (100.9 °F); or

Cervical adenopathy; or

Tonsillar exudates or erythema; or

Policy contains:

Adenoidectomy

Polysomnography.

Sleep apnea.

Tonsillectomy.

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Positive test for Group A β-hemolytic streptococcus.

OR

A history of recurrent throat infections not meeting criteria above, but individual has additional

factors that favor tonsillectomy, including but not limited to:

o Multiple antibiotic allergy/intolerance; or

o Periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome; or

o Peritonsillar abscess; or

o Parapharyngeal abscess.

OR

A diagnosis of sleep-disordered breathing with documentation of all of the following:

o Tonsillar hypertrophy and either of the following:

Abnormalities of respiratory pattern or the adequacy of ventilation during

sleep, including but not limited to snoring, mouth breathing, and pauses in

breathing*; or

A condition related to sleep-disordered breathing (including but not limited to

growth retardation, poor school performance, enuresis, behavioral problems

and/or daytime lethargy) that is likely to improve after tonsillectomy.

OR

A diagnosis of sleep-disordered breathing for a child less than three years of age with

documentation of all of the following:

o Tonsillar hypertrophy; and

o Sleep-disordered breathing is chronic (more than three months in duration); and

o Child's parent or caregiver reports regular episodes of nocturnal choking, gasping,

apnea, or breath holding.

OR

A diagnosis of obstructive sleep apnea with documentation of all of the following:

o Tonsillar hypertrophy; and

o A polysomnogram with an Apnea-Hypopnea Index greater than 1.0.

OR

Suspicion of tonsillar and/or adenoid malignancy (AAFP, 2016; Baugh, 2011).

Limitations:

All other indications for tonsillectomy and/or adenoidectomy are not medically necessary. American

Academy of Otolaryngology-Head and Neck Surgery guidelines state the following:

The above criteria pertain only to complete tonsillectomy, with or without adenoidectomy, and

do not apply to tonsillotomy, intracapsular surgery, or any partial removal of a tonsil because of

the relatively sparse high-quality published evidence on these techniques and limited long-term

follow-up.

Children with diabetes mellitus, cardiopulmonary disease, craniofacial disorders, congenital

anomalies of the head and neck region, sickle cell disease, and other coagulopathies or

immunodeficiency disorders. (Baugh, 2011)

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Alternative covered services:

Physician visits with watchful waiting, close monitoring, and accurately documenting episodes of

pharyngotonsillitis in children with less than seven episodes in the past year, five per year in the past two

years, or three per year in the past three years.

Background

The palatine tonsils are lymphoepithelial organs located at the junction of the oral cavity and the

oropharynx. They are strategically positioned to serve as secondary lymphoid organs, initiating immune

responses against antigens entering the body through the mouth or nose. The greatest immunological

activity of the tonsils is found between the ages of 3 and 10. As a result, the tonsils are most prominent

during this period of childhood and subsequently demonstrate age-dependent involution.

Children with recurrent throat infections have more bodily pain and poorer general health and physical

functioning than those who do not. Tonsillectomy may improve quality of life by reducing throat infections,

health care provider visits, and the need for antibiotic therapy. Similarly, sleep-disordered breathing is

associated with cognitive and behavioral impairment in children that usually improves after tonsillectomy,

along with quality of life, sleep-disturbance, and vocal quality.

Until the 1960s, tonsillectomy was the most frequently performed surgical procedure in the United States;

in the 12-month period July 1960 – June 1961, a total of 611,000 Americans (501,000 age 6 – 16,

underwent a tonsillectomy (NCHS, 1963). Subsequently, the national tonsillectomy rate declined drastically

for decades after. The rate has increased since the 1970s, with the percent of patients with upper airway

obstruction rising from 12 to 77 percent between 1970 and 2005 (Erickson, 2009). The current annual

number of U.S. children under age 15 who undergo tonsillectomy is 530,000 (Baugh, 2011).

While adenotonsillectomy improves polysomnography in children with obstructive sleep apnea, between

13 and 79 percent will have persistent disease. The likelihood of persistent disease is elevated in patients

with obesity, more severe obstructive sleep apnea at baseline, craniofacial anomalies, Down syndrome, or

mucopolysaccharidoses (Garetz, 2017).

The most-recognized guideline addressing when tonsillectomy is indicated is from the American Academy

of Otolaryngology – Head and Neck Surgery, published in 2011. This publication updates a 2000 set of

clinical indicators from the Academy; a major difference in the new guideline was the recommendation that

children should have at least seven episodes of throat infection each year, or at least five episodes each

year for two years, or three episodes annually for three years, before becoming candidates of surgery, a

much stricter standard than the earlier version (three cases of swollen and infected tonsils). The guideline,

which forms the basis for the coverage section of this policy, also strongly recommends against using

antibiotics just before or after tonsillectomy, due to potential allergic reactions (Baugh, 2011). Of 13

pediatric guidelines for certain conditions, the Academy guideline was rated highest, with one exception

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(Hester, 2014).

All recommendations in the American Academy of Family Physicians 2012 guideline on tonsillectomy were

also in the American Academy of Otolaryngology – Head and Neck Surgery guideline (AAFP, 2016).

The American Academy of Otolaryngology – Head and Neck Surgery also issued a practice guideline

recommending polysomnography prior to determining need for tonsillectomy if the child has obesity, Down

syndrome, and other conditions, and for sleep-disordered children with none of these comorbid conditions.

Findings should be communicated to anesthesiologists prior to surgery, and children should be admitted for

overnight monitoring after the tonsillectomy if they are under age three or have severe obstructive sleep

apnea (Roland, 2011).

The American Academy of Pediatrics issued a guideline in 2012 on diagnosis and management of childhood

obstructive sleep apnea syndrome. It recommends adenotonsillectomy as the first-line treatment of

patients with adenotonsillar hypertrophy, and that high-risk patients should be monitored as inpatients

following surgery (Marcus, 2012).

Searches

AmeriHealth Caritas searched PubMed and the databases of:

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other

evidence-based practice centers.

The Centers for Medicare & Medicaid Services (CMS).

We conducted searches on March 21, 2018. Search terms were: “tonsillectomy,” “adenoidectomy,”

“tonsillitis,” “obstructive sleep apnea,” and “sleep-disordered breathing”.

We included:

Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and

greater precision of effect estimation than in smaller primary studies. Systematic reviews use

predetermined transparent methods to minimize bias, effectively treating the review as a

scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

Guidelines based on systematic reviews.

Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple

cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies

— which also rank near the top of evidence hierarchies.

Findings

One of the earlier meta-analyses on tonsillectomy/adenoidectomy including 23 reports (n=1079) affirmed it

to be a valuable first-line treatment for pediatric obstructive sleep apnea/hypopnea syndrome, based on

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the finding of 59.8 percent cured, i.e., apnea-hypopnea index <1 after surgery, but that the procedure does

not cure the apnea (Friedman, 2009). One of the more recent meta-analyses of three reviews observed a

significant (p<.001) improvement in Obstructive Sleep Apnea-18 scores after adenotonsillectomy in

pediatric patients, both short- and long-term (Todd, 2017).

A review of 218 studies by the Agency for Healthcare Research and Quality, 141 of which were randomized

controlled trials, found in the first postoperative year tonsillectomy reduced the number of throat

infections, sleep problems, and work/school absences, but these benefits did not persist over time (Francis,

2017). A systematic review of seven studies (n=2,414) of children with at least three infections in the

previous 1 - 3 years found the same temporary-only benefits after comparing children with recurrent

throat infections who underwent tonsillectomy versus those assigned to “watchful waiting” (Morad, 2017).

Another systematic review of seven studies (n=1133) documented moderately fewer sore throat episodes

in the first year after tonsillectomy surgery, i.e., 3.0 versus 3.6 for controls (Burton, 2014). Reductions of

sore throat episodes in German children after tonsillectomy have been modest; authors note the

proportion of tonsillotomy versus tonsillectomy is rising (Windfuhr, 2016b). Tonsillectomy’s ability to

improve sleep problems is especially great in non-obese children, in a 51-study review of 3,413 children

undergoing the procedure (Lee, 2016).

Long-term benefits of tonsillectomy have been demonstrated in a review of 15 studies (n=3059) of patients

with IgA nephropathy, who had a significantly greater chance of clinical remission and inhibited

development of end stage renal disease (Duan, 2017), which matched results of a 14-study meta-analysis

(n=1794) several years earlier (Liu, 2015).

A Cochrane review of three studies (n=453) noted that adenotonsillectomy is associated with improved

quality of life, symptoms, and behavior for children age 5 – 9 with mild to moderate obstructive sleep

apnea. Seven months after surgery, scores for the surgical group were lower (better) than the watchful

waiting group, at 31.8 to 49.5, and had a higher percent (79 versus 46) of normalization of respiratory events during sleep. However, almost half of the children assigned to be watched rather than undergo surgery

returned to normal within seven months, suggesting that watchful waiting be carefully considered as an

option to surgery in certain cases (Venekamp, 2015).

A meta-analysis of three studies comparing quality of life changes for those with versus without

tonsillectomy (less than 12 months after surgery) found significant improvements for the surgery group in

apnea-hypopnea index, sleep quality, and behavioral outcomes; insufficient strength of evidence was found

for cognitive changes, executive function, cardio-metabolic outcomes, and health care utilization

(Chinnandurai, 2017).

Another systematic review of 14 reviews (n=418) suggested that cardiovascular morbidities involving blood

pressure, heart rate, cardiac morphology, and cardiac function, especially common in children with

obstructive sleep apnea, are reduced in the short term after adenotonsillectomy (Teo, 2013).

A systematic review of 57 studies found that tonsillectomy is not indicated to treat otitis media with

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effusion or periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome. It is effective in

resolving sleep-related breathing disorders, but the benefit is offset by comorbidities such as obesity,

requiring further research (Windfuhr, 2016a).

A systematic review of 18 articles determined that adenotonsillectomy consistently decreased severity of

asthma, as expressed by use of respiratory medicine, asthma-related emergency room visits, overall asthma

symptoms, and asthma-related exacerbations (Kohli, 2016).

Tonsillotomy, also known as intracapsular tonsillectomy, is a modern technique to remove tonsil tissue in

the treatment of obstructive sleep apnea that produces less bleeding and dehydration and requires less

analgesic use than tonsillectomy (Acevedo, 2012). A review of 20 studies (four on tonsillotomy, 16 on

tonsillectomy) found both improved sleep apnea symptoms with no significant differences, suggesting

potential wider use of tonsillotomy may be merited (Gorman, 2017). Another systematic review of 10

studies (n=1029) that compared the two procedures for children with sleep-disordered breathing

documented a significantly greater reduction in breathing problems for those undergoing tonsillotomy in

the short term, but a significantly greater reduction for tonsillectomy in the long term, i.e., 31 months after

surgery (Wang, 2015).

Ten trials (n=1035) of post-tonsillectomy patients given antibiotics revealed a significant reduction in

subjects with fever, but insignificant reductions in significant and secondary hemorrhage rates (p=.45 and

p=.66) and pain, leading authors to advocate against routine prescription of antibiotics to tonsillectomy

patients after surgery (Dhiwakar, 2010).

A comparison between January 2009 and January 2013 at 29 U.S. children’s hospitals evaluated any

changes in utilization and outcomes before and after implementation of the American Academy of

Otolaryngology – Head and Neck Surgery guideline. The number of children undergoing the procedure rose

from 54,043 to 57,770. Antibiotic use decreased from 34.7 to 21.8 percent from 2009-2010 to 2011-2013,

before and after the American Academy of Otolaryngology – Head and Neck Surgery guidelines took place.

Revisits for bleeding remained unchanged; however, total revisits to the hospital increased from 8.2 to 9.0

percent due to revisits for pain (Mahant, 2015).

A review of 24 articles on disparities for prevalence and treatment of child sleep-disordered breathing

found (racial, ethnic, and socioeconomic) minorities had higher prevalence for the disorder, but white

children or children with private insurance were more likely to undergo adenotonsillectomy (Boss, 2011).

Because some pediatric patients continue to experience obstructive sleep apnea after adeontonsillectomy,

new methods are being developed to reduce these cases. A meta-analysis of four studies (n=73) of lingual

tonsillectomies after adenotonsillectomy documented a success rate of 17 percent (postoperative apnea-

hypopnea index <1), while 51 percent had an index <5. Authors judged the technique to be effective in

reducing sleep apnea (Kang, 2017), a result matched by another meta-analysis (Rivero, 2017). An earlier

review found that lingual tonsillectomy patients had a significantly lower apnea-hypopnea index than did

supraglottoplasty patients; studies were of children who were overweight, a known risk factor for the

persistence of sleep apnea after tonsillectomy (Chan, 2012).

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Intracapsular tonsillectomy, which removes tonsil tissue but not the capsule, is another relatively new type

of the procedure. A meta-analysis of 15 randomized controlled trials found significantly better outcomes

for the intracapsular procedure, compared to extracapsular tonsillectomy, for postoperative bleeding

(p=.01), residual tonsils (p=.002), postoperative pain (p=.0022), need for analgesics (p<.0001), days to

normal diet (p=.006) and days to normal activity (p<.0001) (Kim, 2017).

Policy updates:

A total of one guideline/other and eight peer-reviewed references were added to, and one guideline/other

removed from, this policy in March 2018.

Summary of clinical evidence:

Citation Content, Methods, Recommendations

Kim (2017)

Outcomes, tonsillotomy

vs. tonsillectomy

Key points:

Meta-analysis of 15 randomized controlled trials.

Comparison of outcomes after tonsillectomy vs. tonsillotomy (intracapsular tonsillectomy).

Significantly better outcomes observed for tonsillotomy, for postoperative bleeding (p=.01),

residual tonsils (p=.002), postoperative pain (p=.0022), need for analgesics (p<.0001), days to

normal diet (p=.006) and days to normal activity (p<.0001).

Francis (2017)

Tonsillectomy for

obstructive sleep

disordered breathing or

recurrent throat

infection in children

Key points:

Systematic review of 218 studies (141 of which are randomized controlled trials).

Most children with obstructive sleep-disordered breathing undergoing tonsillectomy (vs. no

surgery) reported better sleep-related outcomes.

Tonsillectomy in children with recurrent throat infections reduced the number of infections and

work/school absences in the first year after surgery, but the reduction did not continue after the

first year.

Bleeding associated with perioperative dexamethasone vs. placebo did not indicate increased

risk of bleeding with steroids.

Post-tonsillectomy hemorrhage was <4%, bleeding associated revisits or reoperations was

<8%.

Gorman (2017)

Tonsillectomy vs.

tonsillotomy in children

with obstructive sleep

apnea

Key points:

Meta-analysis of 20 studies, 16 on tonsillectomy and four on tonsillotomy.

Improvement in obstructive sleep apnea was not significantly different between the two

methods.

Wider use of tonsillotomy vs. tonsillectomy should be considered.

Kohli (2016)

Effects of

adenotonsillectomy on

Key points:

Systematic review of four articles on asthma outcomes after adenotonsillectomy for children.

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Citation Content, Methods, Recommendations

childhood asthma Markers of asthma severity included respiratory medication use, emergency room visits for

asthma-related symptoms, overall asthma symptoms, and asthma-related exacerbations.

All of the above markers were reduced following adenotonsillectomy.

More prospective trials are needed to better understand causal relationship between the

procedure and asthma.

Venekamp (2015)

Tonsillectomy vs. non-

surgical management

for obstructive sleep

disordered breathing

Key points:

Cochrane review of three studies (n=562 children), results could not be pooled.

Trials compared adenotonsillectomy vs. no surgery or continuous positive airway pressure

(CPAP).

Quality of life improved significantly for surgical vs. watchful waiting groups.

No significant difference in improvements for surgical vs. CPAP groups.

References

Professional society guidelines/other:

American Academy of Family Physicians (AAFP). Clinical Practice Guideline: Tonsillectomy in Children.

Leawood KS: AAFP, last evaluated 2016.http://www.aafp.org/patient-care/clinical-

recommendations/all/tonsil.html. Accessed March 21, 2018.

Baugh RF, Archer SM, Mitchell RB, et al. American Academy of Otolaryngology–Head and Neck Surgery

Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(1

Suppl):S1 – 30.

Marcus CL, Brooks LJ, Draper KA, et al. American Academy of Pediatrics. Diagnosis and management of

childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):576 – 84.

National Center for Health Statistics (NCHS). Length of convalescence after surgery, July 1960 – June 1961.

Washington DC: U.S. Department of Health, Education, and Welfare, June 1963.

https://www.cdc.gov/nchs/data/series/sr_10/sr10_003acc.pdf. Accessed March 21, 2018.

Randel A. AAO-HNS guidelines for tonsillectomy in children and adolescents. Am Fam Physician.

2011;84(5):566 – 73. www.aafp.org/afp/2011/0901/p566.pdf. Accessed March 21, 2018.

Roland PS, Rosenfeld RM, Brooks LJ, et al. American Academy of Otolaryngology–Head and Neck Surgery

Foundation. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to

tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 Suppl):S1 – 15.

Peer-reviewed references:

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Acevedo JL, Shah RK, Brietzke SE. Systematic review of complications of tonsillotomy versus tonsillectomy.

Otolaryngol Head Neck Surg. 2012;146(6):871 – 79.

Blakley BW, Magit AE. The role of tonsillectomy in reducing recurrent pharyngitis: a systematic review.

Otolaryngol Head Neck Surg. 2009;140(3):291 – 97.

Boss EF, Smith DF, Ishman SL. Racial/ethnic and socioeconomic disparities in the diagnosis and treatment of

sleep-disordered breathing in children. Int J Pediatr Otorhinolaryngol. 2011;75(3):299 – 307.

Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Tonsillectomy or adenotonsillectomy versus non-surgical

treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014;(11):CD001802. Doi:

10.1002/14651858.CD001802.pub3.

Chan DK, Jan TA, Koltai PJ. Effect of obesity and medical comorbidities on outcomes after adjunct surgery

for obstructive sleep apnea in cases of adenotonsillectomy failure. Arch Otolaryngol Head Neck Surg.

2012;138(10):891 – 96.

Chinnadurai S, Jordan AK, Sathe NA, Fonnesbeck C, McPheeters ML, Francis DO. Tonsillectomy for

obstructive sleep-disordered breathing: A meta-analysis. Pediatrics. 2017;139(2). pii: e20163491. doi:

10.1542/peds.2016-3491.

Dhiwakar M, Clement WA, Supriya M, McKerrow W. Antibiotics to reduce post-tonsillectomy morbidity.

Cochrane Database Syst Rev. 2010;(7):CD005607. Doi: 10.1002/14651858.CD005607.pub3.

Duan J, Liu D, Duan G, Liu Z. Long-term efficacy of tonsillectomy as a treatment in patients with IgA

nephropathy: a meta-analysis. Int Urol Nephrol. 2017;49(1):103 – 12.

Erickson BK, Larson DR, St Sauver JL, Meverden RA, Orvidas LJ. Changes in incidence and indications of

tonsillectomy and adenotonsillectomy, 1970-2005. Otolaryngol Head Neck Surg. 2009;140(6):894 – 901.

Francis DO, Chinnadurai S, Sathe NA, et al. Tonsillectomy for obstructive sleep-disordered breathing or

recurrent throat infection in children [internet]. Rockville, MD: Agency for Healthcare Research and

Quality;2017 January report no. 16(17)-EHC042-EF.

Friedman M, Wilson M, Lin HC, Chang HW. Updated systematic review of tonsillectomy and adenoidectomy

for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg.

2009;140(6):800 – 08.

Garetz SL. Adenotonsillectomy for obstructive sleep apnea in children. Up to Date. Last updated

November 27, 2017. https://www.uptodate.com/contents/adenotonsillectomy-for-obstructive-sleep-

apnea-in-children. Accessed March 21, 2018.

Gorman D, Ogston S, Hussain SS. Improvement in symptoms of obstructive sleep apnoea in children

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following tonsillectomy versus tonsillotomy: a systematic review and meta-analysis. Clin Otolaryngol.

2017;42(2):275 – 82.

Hester G, Nelson K, Mahant S, Eresuma E, Keren R, Srivastava R. Methodological quality of national

guidelines for pediatric inpatient conditions. J Hosp Med. 2014;9(6):384 – 90.

Kang KT, Koltai PJ, Lee CH, Lin MT, Hsu WC. Lingual tonsillectomy for treatment of pediatric obstructive

sleep apnea: A meta-analysis. JAMA Otolaryngol Head Neck Surg. 2017;143(6):561 – 68.

Kim JS, Kwon SH, Lee EJ, Yoon YJ. Can intracapsular tonsillectomy be an alternative to classical

tonsillectomy? A meta-analysis. Otolaryngol Head Neck Surg. 2017;157(2):178 – 89.

Kohli N, DeCarlo D, Goldstein NA, Silverman J. Asthma outcomes after adenotonsillectomy: a systematic

review. Int J Pediatr Otorhilolaryngol. 2016;90:107 – 12.

Lee CH, Hsu WC, Chang WH, Lin MT, Kang KT. Polysomnographic findings after adenotonsillectomy for

obstructive sleep apnoea in obese and non-obese children: a systematic review and meta-analysis. Clin

Otolaryngol. 2016;41(5):498 – 510.

Liu LL, Wang LN, Jiang Y, et al. Tonsillectomy for IgA nephropathy: a meta-analysis. Am J Kidney Dis.

2015;65(1):80 – 87.

Mahant S, Hall M, Ishman SL, et al. Association of National Guidelines with tonsillectomy perioperative care

and outcomes. Pediatrics. 2015;136(1):53 – 60.

Morad A, Sathe NA, Francis DO, McPheeters ML, Chinnadurai S. Tonsillectomy versus watchful waiting for

recurrent throat infection: a systematic review. Pediatrics. 2017;139(2). Epub January 17, 2017.

Rivero A, Durr M. Lingual tonsillectomy for pediatric persistent obstructive sleep apnea: A systematic

review and meta-analysis. Otolaryngol Head Neck Surg. 2017;157(6):940 – 47.

Teo DT, Mitchell RB. Systematic review of effects of adenotonsillectomy on cardiovascular parameters in

children with obstructive sleep apnea. Otolaryngol Head Neck Surg. 2013;148(1):21 – 28.

Todd CA, Bareiss AK, McCoul ED, Rodriguez KH. Adenotonsillectomy for obstructive sleep apnea and quality

of life: Systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2017;157(5):767 – 73. Doi:

10.1177/0194599817717480.

Venekamp RP, Hearne BJ, Chandrasekharan D, Blackshaw H, Lim J, Schilder AG. Tonsillectomy or

adenotonsillectomy versus non-surgical management for obstructive sleep-disordered breathing in

children. Cochrane Database Syst Rev. 2015;(10):CD011165. Doi: 10.1002/14651858.CD011165.pub2.

Wang H, Fu Y, Feng Y, Guan J, Yin S. Tonsillectomy versus tonsillotomy for sleep-disordered breathing in

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children: a meta analysis. PLoS One. 2015;10(3):e0121500.

Windfuhr JP. Indications for tonsillectomy stratified by the level of evidence. GMS Curr Top

Otorhinolaryngol Head Neck Surg. 2016a. Doi: 10.3205/cto000136. Doi: 10.1007/s00405-015-3872-6.

Windfuhr JP, Toepfner N, Steffen G, Waldfahrer F, Berner R. Clinical practice guideline: tonsillitis II. Surgical

management. Eur Arch Otorhinolaryngol. 2016b;273(4):989 – 1009.

CMS National Coverage Determinations (NCDs):

No NCDs identified as of the writing of this policy.

Local Coverage Determinations (LCDs):

No LCDs identified as of the writing of this policy.

Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not

an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill

accordingly.

CPT Code Description Comments

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.

42830 Adenoidectomy, primary; younger than age 12.

42835 Adenoidectomy, secondary, younger than age 12.

42870 Excision or destruction lingual tonsil, any method (separate procedure).

ICD-10 Code Description Comments

G47.33 Obstructive sleep apnea (adult) (pediatric).

J03.90 Acute tonsillitis, unspecified.

J03.91 Acute recurrent tonsillitis, unspecified.

J35.01 Chronic tonsillitis.

J35.02 Chronic adenoiditis.

J35.1 Hypertrophy of tonsils.

J35.2 Hypertrophy of adenoids.

J35.3 Hypertrophy of tonsils with hypertrophy of adenoids.

J35.8 Other chronic disease of tonsils and adenoids.

J35.9 Chronic disease of tonsils and adenoids, unspecified.

J36 Peritonsillar abscess

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HCPCS

Level II Code Description Comments

N/A No applicable codes

Note: The American Academy of Otolaryngology–Head and Neck Surgery has published a multidisciplinary,

evidence-based clinical practice guideline, "Tonsillectomy in Children.” The new guideline provides

evidence-based recommendations on the preoperative, intraoperative, and postoperative care and

management of children ages 1 to 18 years under consideration for tonsillectomy and is intended for all

clinicians in any setting who care for these patients. This guideline also addresses practice variation in

medicine and the significant public health implications of tonsillectomy (Hayes, Jan. 5, 2011).