Anthem Blue Cross Connecticut CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults Form

This document addresses tonsillectomy in adults with or without adenoidectomy. This surgery has been widely accepted as a treatment for recurrent or chronic throat infections, tonsil hypertrophy, and obstructive sleep apnea (OSA).

Note: For information regarding related procedures, please see:

• CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy
• CG-SURG-36 Adenoidectomy
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Clinical Indications

Medically Necessary:

Tonsillectomy is considered medically necessary for individuals 18 years of age and older who meet one or more of the criteria below:

1. A history of recurrent acute throat infection with a frequency of at least:
   1. Three or more episodes in the previous 6 months; or
   2. Four or more episodes in the previous 12 months;
      and
   3. Documentation in the medical record for each episode of sore throat which includes at least one of the following:
      1. Temperature greater than 38.3 °C (100.9 °F); or
      2. Cervical adenopathy; or
      3. Tonsillar exudate or erythema; or
      4. Positive test for Group A ß-hemolytic streptococcus (GABHS);
         or
2. A history of recurrent acute throat infections not meeting criteria above, but individual has additional factors that favor tonsillectomy, including but not limited to:
   1. Multiple antibiotic allergy/intolerance; or
   2. One or more peritonsillar abscess; or
   3. One or more parapharyngeal abscesses;
      or
3. A history of chronic throat infections, as indicated by 1 or more of the following:
   1. Chronic tonsillitis with all of the following:
      1. Inflammation or infection (symptoms may include pain and discomfort, airway obstruction, and dysphagia); and
      2. Persists for 3 or more months; and
      3. Resistant to medical treatment;
         or
   2. Infectious mononucleosis with all of the following:
      1. Failure to respond to corticosteroid; and
      2. Tonsillar hypertrophy causing airway obstruction or dysphagia;
         or
4. A diagnosis of obstructive sleep apnea (OSA) with documentation of all of the following:
   1. Tonsillar hypertrophy; and
   2. Polysomnographic evidence of OSA with either:
      1. AHI or RDI greater than or equal to 15 events per hour;
         or
      2. AHI or RDI greater than or equal to 5 events per hour, and less than 15 events per hour with documentation demonstrating any of the following symptoms:
         1. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities; or
         2. Impaired cognition or mood disorders; or
         3. Hypertension; or
         4. Ischemic heart disease or history of stroke; or
         5. Cardiac arrhythmias, or
         6. Pulmonary hypertension;
            or
5. IgA nephropathy;
   or
6. Known or suspected tonsillar malignancy.

Not Medically Necessary:

Tonsillectomy is considered not medically necessary for individuals 18 years of age and older when the criteria above have not been met, and in all other circumstances.