Clinical UM Guideline


Subject:Tonsillectomy for Children
Guideline #:   CG-SURG-30Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:   11/14/2013

Description

This document addresses tonsillectomy in children.  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).  This document does not address adenoidectomy separate from tonsillectomy.

For information relating to adenoidectomy separate from tonsillectomy, please see:

Clinical Indications

Medically Necessary

Tonsillectomy is considered medically necessary for individuals less than 18.0 years of age who meet one or more of the criteria below:

  1. A history of recurrent throat infection with a frequency of at least:
    • 7 episodes in the past year; or
    • 5 episodes per year for 2 years; or
    • 3 episodes per year for 3 years;
      AND
    • 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
      • Positive test for Group A β-hemolytic streptococcus (GABHS).
        OR
  2. A history of recurrent throat infections not meeting criteria above, but individual has additional factors that favor tonsillectomy, including but not limited to:
    • Multiple antibiotic allergy/intolerance; or
    • PFAPA (Periodic fever, aphthous stomatitis, pharyngitis, and adenitis) syndrome; or
    • Peritonsillar abscess; or
    • Parapharyngeal abscess.
      OR
  3. A diagnosis of sleep-disordered breathing (SDB) with documentation of all of the following:
    • Tonsillar hypertrophy; and
    • Abnormalities of respiratory pattern or the adequacy of ventilation during sleep, including but not limited to snoring, mouth breathing, and pauses in breathing*; and
    • A condition related to SDB (including but not limited to growth retardation, poor school performance, enuresis, and behavioral problems) that is likely to improve after tonsillectomy.
      OR
  4. A diagnosis of SDB for a child less than 3 years of age with documentation of all of the following:
    • Tonsillar hypertrophy; and
    • SDB is chronic (more than 3 months in duration); and
    • Child's parent or caregiver reports regular episodes of nocturnal choking, gasping, apnea, or breath holding.
      OR
  5. A diagnosis of obstructive sleep apnea (OSA) with documentation of all of the following:
    • Tonsillar hypertrophy; and
    • A polysomnogram with an Apnea-Hypopnea Index (AHI) greater than 1.0.
      OR
  6. Suspicion of tonsillar malignancy.

*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.

Coding

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.

CPT 
42820Tonsillectomy and adenoidectomy; younger than age 12
42821Tonsillectomy and adenoidectomy; age 12 or over
42825Tonsillectomy, primary or secondary, younger than age 12
42826Tonsillectomy, primary or secondary, age 12 or over
  
ICD-9 Procedure[For dates of service prior to 10/01/2014]
28.2Tonsillectomy without adenoidectomy
28.3Tonsillectomy with adenoidectomy
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Procedure[For dates of service on or after 10/01/2014]
0CTP0ZZResection of tonsils, open approach
0CTPXZZResection of tonsils, external approach
  
ICD-10 Diagnosis[For dates of service on or after10/01/2014]
 All diagnoses
  
Discussion/General Information

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.  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:

  1. "Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3o C, cervical adenopathy, tonsillar exudate, or positive test for GABHS."
  2. "Clinicians should assess the child with recurrent throat infection who does not meet criteria in Statement 2 for modifying factors that may nonetheless favor tonsillectomy,which may include but are not limited to multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of peritonsillar abscess."
  3. "Clinicians should ask caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems."

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, 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.  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, that 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 American Academy of Pediatrics (AAP) and AAO-HNS regard tonsillectomy as a reasonable option for any child with documented OSA.

Definitions

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.

References

Peer Reviewed Publications:

  1. Blakley BW, Magit AE. The role of tonsillectomy in reducing recurrent pharyngitis: a systematic review. Otolaryngol Head Neck Surg. 2009; 140(3):291-297.
  2. Brietzke SE, Gallagher D. The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg. 2006; 134(6):979-984.
  3. 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):800-808.
  4. Garavello W, Romagnoli M, Gaini RM. Effectiveness of adenotonsillectomy in PFAPA syndrome: a randomized study. J Pediatr. 2009; 155(2):250-253.
  5. Paradise JL, Bluestone CD, Colborn DK, et al. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics. 2002; 110(1 Pt 1):7-15.
  6. Stewart MG, Glaze DG, Friedman EM, et al. Quality of life and sleep study findings after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2005; 131(4):308-314.
  7. Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. 2006; 149(6):803-808.
  8. van Staaij BK, van den Akker EH, Rovers MM, et al. Effectiveness of adenotonsillectomy in children with mild symptoms of throat infections or adenotonsillar hypertrophy: open, randomized controlled trial. BMJ. 2004; 329(7467):651.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS). Clinical Indicators: Tonsillectomy, Adenoidectomy, Adenotonsillectomy in Childhood.  2011. Available at: http://www.entnet.org/Practice/upload/TA_Adenotonsillectomy-CI_May-2012.pdf. Accessed on September 12, 2013.
  2. American Academy of Pediatrics. Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002; 109(4):704-712.
  3. Au CT, Li AM. Obstructive sleep breathing disorders. Pediatr Clin N Am. 2009; 56(1):243–259.
  4. 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.
  5. Burton MJ, Glasziou PP. Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2009; (1):CD001802.
  6. Burton MJ, Pollard AJ, Ramsden JD. Tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA). Cochrane Database Syst Rev. 2010; (9):CD008669.
  7. Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in children. Am Fam Physician 2004; 69(5):1147-1154, 1159-1160.
  8. Lim J, McKean MC. Adenotonsillectomy for obstructive sleep apnoea in children. Cochrane Database Syst Rev. 2009; (2):CD003136.
  9. Marcus CL, Brooks LJ, Draper, KA. et al. American Academy of Pediatrics Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics. 2012; 130;576-584.
  10. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancer (V.2.2013). May 29, 2013.  For additional information: http://www.nccn.org/.  Accessed on September 13, 2013.
  11. Petcu LG, Goodman IS, Burns JJ.  Chapter 331: Tonsillectomy and Adenoidectomy. In: AAP Textbook of Pediatric Care. McInerny TK, Adam, HM, Campbell DE, et al. eds. 2013. Available at: https://www.pediatriccareonline.org/pco/ub/view/AAP-Textbook-of-Pediatric-Care/394000/0/___Front_Matter___?amod=aapea&login=true&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token.  Accessed on September 4, 2013.
  12. Spruyt K, Pediatric Sleep disordered breathing: criteria and spectrum of disease. In: Pediatric Sleep disordered breathing in children: a comprehensive clinical guide to evaluation and treatment. Kheirandish-Gozal L; Gozal D (Eds.). Springer; New York, NY. 2012.
Web Sites for Additional Information
  1. National Library of Medicine. Sleep apnea.  Available at: http://www.nlm.nih.gov/medlineplus/sleepapnea.html. Accessed on October 8, 2013.
  2. National Library of Medicine. Tonsillectomies and children. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001998.htm. Accessed on October 8, 2013.
Index

Adenotonsillectomy
Obstructive sleep apnea
PFAP
Sleep disordered breathing
Tonsillectomy

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.

History
StatusDateAction
Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion  and Reference sections.
Revised11/08/2012MPTAC 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.
Revised08/09/2012MPTAC review. Clarified age criteria in the position statement.
New02/16/2012MPTAC review. Initial document development.