Anthem Blue Cross Connecticut CG-SURG-36 Adenoidectomy Form

This document addresses the use of adenoidectomy, a surgical procedure to remove the adenoids, which are also known as pharyngeal tonsils or nasopharyngeal tonsils. Adenoidectomy is a common surgical procedure used to treat an array of conditions.

Note: This document only applies to adenoidectomy alone. Please see the following document if tonsillectomy is proposed in addition to adenoidectomy:

• CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy
• CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Clinical Indications

Medically Necessary:

Adenoidectomy is considered medically necessary for individuals when any of the following conditions are met:

1. Suspected adenoid tumor based on imaging (for example, CT), nasopharyngoscopy or endoscopy; or
2. Chronic (greater than or equal to 12 weeks in duration) adenoiditis with rhinorrhea, despite a minimum of 3 weeks of appropriate antibiotic treatment; or
3. Chronic (greater than or equal to 12 weeks in duration) rhinosinusitis, despite a minimum of 3 weeks of appropriate antibiotic treatment and one or more of the following:
   1. CT findings suggestive of obstruction or infection (for example, but not limited to, air fluid levels, air bubbles, significant mucosal thickening, pansinusitus, or diffuse opacification); or
   2. Nasal endoscopy findings suggestive of significant disease; or
   3. Physical exam findings suggestive of chronic/recurrent disease (for example mucopurulence, erythema, edema, inflammation); or
4. Four or greater episodes of recurrent adenoiditis with purulent rhinorrhea in the prior 12 months in a child less than 12 years of age. At least one episode should be documented by intranasal examination or diagnostic imaging; or
5. Chronic otitis media with effusion (OME) in children 4 to 17 years of age with a history of prior failed tube tympanostomy and no evidence of nasal obstruction, recurrent sinusitis, or chronic sinusitis, when done in conjunction with either a) myringotomy or b) tube tympanostomy; or
6. Adenoid hypertrophy documented by imaging (for example, lateral neck x-ray), nasopharyngoscopy or endoscopy with symptomatic airway obstruction as demonstrated by any of the following:
   1. In children less than 3 years of age, sleep-disordered breathing (SDB) with documentation of symptoms for more than 3 months in duration and the child’s parent or caregiver reports regular episodes of nocturnal choking, gasping, apnea, or breath holding; or
   2. In children 3 to 17 years of age, SDB with documentation of abnormalities of respiratory pattern or the adequacy of ventilation during sleep, including but not limited to snoring, mouth breathing, and pauses in breathing*; or
   3. 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 adenoidectomy; or
   4. Obstructive sleep apnea as diagnosed by polysomnogram with an Apnea-Hypopnea Index (AHI) greater than 1.0.

*Note: Documentation of SDB can be made based on 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:

Adenoidectomy is considered not medically necessary for all other indications and when criteria above are not met, including, but not limited to, use in children less than 4 years of age with acute or recurrent otitis media.