Tonsillectomy/Adenoidectomy

Last Review Date: January 19, 2017 Number: MG.MM.SU.58C

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Definitions

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.
Organs of the lymphatic system located at the back of the throat. The purpose of the tonsils is to capture germs
Tonsils
entering the body through the mouth and nose.
Sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, which may or may not be
Throat infection culture positive for group A streptococcus. (Includes the terms strep throat and acute tonsillitis, pharyngitis,
adenotonsillitis or tonsillopharyngitis)
A surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its
Tonsillectomy
capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall
Characterized by abnormalities of respiratory pattern or the adequacy of ventilation during sleep, which include
snoring, mouth breathing, and pauses in breathing. SDB encompasses a spectrum of obstructive disorders that
Sleep-disordered increases in severity from primary snoring to obstructive sleep apnea (OSA). Daytime symptoms associated with
breathing SDB may include excessive sleepiness, inattention, poor concentration, and hyperactivity.
Note: A detailed history and physical exam is sufficient to diagnose SDB. Polysomnography (aka sleep study) is not
considered medically necessary.
Medical condition characterized by recurrent episodes of periodic fever, aphthous stomatitis, pharyngitis, and
PFAPA
adenitis.

Guidelines
A. Adenoidectomy
B. Tonsillectomy with or without adenoidectomy
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A. Adenoidectomy medically necessary as follows:

Member of any age with suspected adenoid tumor (based on imaging, nasopharyngoscopy or endoscopy)
OR
Member is 18 years of age and any of the following criteria are met:
1. Chronic adenoiditis with rhinorrhea of 12 weeks in duration despite 3 weeks of pharmacotherapy
2. Chronic rhinosinusitis of 12 weeks duration despite 3 weeks of pharmacotherapy and at least one:
a. CT findings suggestive of obstruction/infection (e.g., air fluid levels, air bubbles, significant
mucosal thickening, pansinusitis or diffuse opacification)
b. Nasal endoscopic findings suggestive of significant disease
c. Physical exam suggestive of chronic/recurrent disease (e.g., mucopurulence, erythema, edema,
inflammation, etc.)
3. Member < 12 years of age with recurrent adenoiditis and purulent rhinorrhea of 4 episodes in 12
preceding months
4. Member 4 years of age with adenoid hypertrophy and chronic otitis media with effusion (OME) and a
positive history of failed tube tympanostomy without evidence of nasal obstruction, recurrent sinusitis
or chronic sinusitis (when done in conjunction with myringotomy or tube tympanostomy)
5. Adenoid hypertrophy with symptomatic airway obstruction documented through imaging,
nasopharyngoscopy or endoscopy and demonstrated by any:
a. Member < 3 years of age with SDB symptoms of > 3 months duration and reported episodes of
nocturnal choking, gasping, apnea or breath holding on a regular basis
b. Member 317 years of age with SDB and abnormalities of respiratory pattern or adequacy of
ventilation during sleep (including but not limited to snoring, mouth breathing and pauses in
breathing)
c. Presence of condition related to SDB that is likely to improve after adenoidectomy (e.g.,
growth retardation, poor school performance, enuresis, behavioral health issues, etc.)
d. Obstructive sleep apnea (OSA) diagnosed by polysomnography (See also Obstructive Sleep
Apnea Diagnosis and Treatment)

B. Tonsillectomy (with our without adenoidectomy) medically necessary as follows:

Member is 18 years of age and 1 of the following criteria are met:
1. A history of recurrent throat infection with a frequency of any:
a. 7 episodes in past year
b. 5 episodes per year for 2 years
c. 3 episodes per year for 3 years
Medical record should reflect 1 of the following per each episode of sore throat:
a. Temperature > 38.3 C (100.9 F)
b. Cervical adenopathy
c. Tonsillar exudates or erythema
d. Positive test for Group A -hemolytic streptococcus (GABHS)
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2. Positive history of recurrent throat infections not meeting criteria above, but member has additional
factors that favor tonsillectomy; these include but are not to any:
a. Multiple antibiotic allergy/intolerance
b. Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome
c. Peritonsillar abscess
d. Parapharyngeal abscess

3. Positive SDB diagnosis with documentation of all:

a. Tonsillar hypertrophy
b. Abnormalities of respiratory pattern or the adequacy of ventilation during sleep, including but
not limited to snoring, mouth breathing, and pauses in breathing
c. Presence of condition related to SDB that is likely to improve after adenoidectomy (e.g., growth
retardation, poor school performance, enuresis, behavioral health issues, etc.)

4. Member of < 3 years of age with SDB with documentation of all:

a. Tonsillar hypertrophy
b. Chronic SDB (lasting > 3 months in duration)
c. SDB symptoms of > 3 months duration and reported episodes of nocturnal choking, gasping,
apnea or breath holding on a regular basis

5. Positive OSA diagnosis with documentation of all:

a. Tonsillar hypertrophy
b. OSA diagnosed by polysomnography (See also Obstructive Sleep Apnea Diagnosis and
Treatment)

6. Suspicion of tonsillar malignancy

Applicable Procedure Codes

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
42831 Adenoidectomy, primary; age 12 or over
42835 Adenoidectomy, secondary; younger than age 12
42836 Adenoidectomy, secondary; age 12 or over

Applicable ICD-10 Diagnosis Codes

C09.8 Malignant neoplasm of overlapping sites of tonsil
C09.9 Malignant neoplasm of tonsil, unspecified
D10.4 Benign neoplasm of tonsil
G47.30 Sleep apnea, unspecified
G47.33 Obstructive sleep apnea (adult) (pediatric)
G47.39 Other sleep apnea
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H65.20 Chronic serous otitis media, unspecified ear

H65.21 Chronic serous otitis media, right ear
H65.22 Chronic serous otitis media, left ear
H65.23 Chronic serous otitis media, bilateral
H66.3x1 Other chronic suppurative otitis media, right ear
H66.3x2 Other chronic suppurative otitis media, left ear
H66.3x3 Other chronic suppurative otitis media, bilateral
H66.3x9 Other chronic suppurative otitis media, unspecified ear
H66.90 Otitis media, unspecified, unspecified ear
H66.91 Otitis media, unspecified, right ear
H66.92 Otitis media, unspecified, left ear
H66.93 Otitis media, unspecified, bilateral
J02.0 Streptococcal pharyngitis
J03.01 Acute recurrent streptococcal tonsillitis
J03.81 Acute recurrent tonsillitis due to other specified organisms
J03.91 Acute recurrent tonsillitis, unspecified
J35.01 Chronic tonsillitis
J35.02 Chronic adenoiditis
J35.03 Chronic tonsillitis and adenoiditis
J35.1 Hypertrophy of tonsils
J35.2 Hypertrophy of adenoids
J35.3 Hypertrophy of tonsils with hypertrophy of adenoids
J35.9 Chronic disease of tonsils and adenoids, unspecified
J36 Peritonsillar abscess

References
1. 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.
2. Au CT, Li AM. Obstructive sleep breathing disorders. Pediatr Clin N Am. 2009; 56(1):243-259.
3. 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.
4. Blakley BW, Magit AE. The role of tonsillectomy in reducing recurrent pharyngitis: a systematic review. Otolaryngol Head Neck
Surg. 2009; 140(3):291-297.
5. 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.
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. 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.
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11. 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(3):576-584.
12. Marcus CL, Moore RH, Rosen CL, et al.; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for
childhood sleep apnea. N Engl J Med. 2013; 368(25):2366-2376.
13. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancer. V2.2016.
http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf. Accessed January 24, 2017.
14. 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.
15. Specialty matched clinical peer review.
16. 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
17. 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.
18. Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J
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