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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)
3
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).
7
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.
8
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:
9
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
10
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
11
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
12
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).