Clinical UM Guideline

This document addresses tonsillectomy in children with or without adenoidectomy. 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).

Note: This document does not address adenoidectomy separate from tonsillectomy.

Note:For information regarding related procedures, please see:

• CG-SURG-36 Adenoidectomy
• CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion
• CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

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:
   1. Seven episodes in the past year; or
   2. Five episodes per year for 2 years; or
   3. Three episodes per year for 3 years; 
      and
   4. 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 exudates or erythema; or
      4. 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:
   1. Multiple antibiotic allergy/intolerance; or
   2. Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome; or
   3. Peritonsillar abscess; or
   4. Two or more parapharyngeal abscesses. 
      or
3. A diagnosis of sleep-disordered breathing (SDB) with documentation of the following:
   1. Tonsillar hypertrophy and either of the following:
      1. Abnormalities of respiratory pattern or the adequacy of ventilation during sleep, including but not limited to snoring, mouth breathing, and pauses in breathing*; or
      2. A condition related to SDB (including but not limited to growth retardation, poor school performance, enuresis, asthma, 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:
   1. Tonsillar hypertrophy; and
   2. SDB is chronic (more than 3 months in duration); and
   3. 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:
   1. Tonsillar hypertrophy; and
   2. 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.

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.

When services are Medically Necessary:

When services may be Medically Necessary when criteria are met:
For the procedure codes listed above for the following diagnoses

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed.

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 of age. 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, post-tonsillectomy hemorrhage (PTH), 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 (Mitchell, 2019). In this guideline, they recommend the following:

1. STATEMENT 2: RECURRENT THROAT INFECTION WITH DOCUMENTATION:
   Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, 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 1 or more of the following: temperature >38.3^oC (101^oF), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.
2. STATEMENT 3. TONSILLECTOMY FOR RECURRENT INFECTION WITH MODIFYING FACTORS:
   Clinicians should assess the child with recurrent throat infection who does not meet criteria in Key Action 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 > 1 peritonsillar abscess.
3. STATEMENT 4. TONSILLECTOMY FOR OBSTRUCTIVE SLEEP-DISORDERED BREATHING:
   Clinicians should ask caregivers of children with obstructive sleep disordered breathing (oSDB) and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems.
4. STATEMENT 7. TONSILLECTOMY FOR OBSTRUCTIVE SLEEP APNEA:
   Clinicians should recommend tonsillectomy for children with obstructive sleep apnea (OSA) documented by overnight polysomnography (PSG). Recommendation based on randomized controlled trial and observational before-and-after studies with a preponderance of benefit over harm.

It should be noted that the AAO-HNS guideline states the following:

The guideline does not apply to populations of children excluded from most tonsillectomy research studies, including those with neuromuscular disease, diabetes mellitus, chronic cardiopulmonary disease, congenital anomalies of the head and neck region, coagulopathies, or immunodeficiency.

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, the use of snoring as a criterion for 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, which block 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 Apnea-Hypopnea Index (AHI) is an indication of OSA (Au, 2009; Chan, 2004; Spruyt, 2012). Both the American Academy of Pediatrics (AAP; Burns, 2017; Marcus, 2012) and AAO-HNS (Baugh, 2011) regard tonsillectomy as a reasonable option for any child with documented OSA.

In 2013, Marcus et al. published results of a single-blind randomized controlled trial (RCT), the Childhood Adenotonsillectomy Trial (CHAT). This trial involved 464 children, 5 to 9 years of age, with OSA, 400 of whom completed the trial (86%). Subjects were randomized to either watchful-waiting (n=203) or early adenotonsillectomy (n=194) and followed for 7 months after randomization. The primary outcome, the attention and executive function score on the Developmental Neuropsychological Assessment, did not differ significantly at follow-up (p=0.16). However, the authors reported that there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group vs. the watchful-waiting group. Furthermore, normalization of polysomnographic findings was observed in a larger proportion of subjects in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). They conclude that their findings provide evidence of beneficial effects of early adenotonsillectomy.

A secondary analysis of the CHAT trial was published in 2021 by Gourishetti and colleagues. The question they sought to answer was whether the AHI threshold chosen as an indication of OSA is predictive of post-adenotonsillectomy changes. Neurocognition, behavior, symptoms of OSA and quality of life were measured at baseline and at the 7 month follow-up after grouping children based on whether their AHI was greater than or equal to 5. The authors found that these outcomes did not differ in children randomized to watchful waiting or to adenotonsillectomy based on the OSA severity threshold alone. The effects of adenotonsillectomy on post-treatment outcomes also were not different based on AHI threshold. These results highlight the limited utility of AHI in measuring the severity of OSA and the importance of preoperative history and physical examination in guiding treatment of OSA.

In another secondary analysis of CHAT trial data, Castro‐Rodriguez and colleagues (2023) found that adenotonsillectomy decreased the risk of wheezing at 7 months of follow‐up. In children in the adenotonsillectomy arm, the prevalence of wheezing significantly decreased from baseline to follow‐up (47% vs. 21.6%, p < 0.001) but did not change in the watchful-waiting arm (45.2% vs. 43.1%, p = 0.67). When the children were grouped by having “any wheezing” versus “no wheezing”, a multivariate analysis found that socioeconomic factors influenced the risk of wheezing. Children in the “any wheezing” group had more eczema, second‐hand smoke exposure, allergic rhinitis, body mass index, higher AHI and had lower maternal education and family income than those in the “no wheezing” group.

In 2017 the Agency for Healthcare Research and Quality (AHRQ) published a comparative effectiveness review titled Tonsillectomy for obstructive sleep-disordered breathing or recurrent throat infection in Children. This document concluded the following:

Tonsillectomy can produce short-term improvement in sleep outcomes and reduction in throat infections compared with no surgery in children with OSDB or recurrent throat infections. Relative to no intervention, most studies reported better sleep-related outcomes in children with OSDB who had a tonsillectomy, but longer term data on durability of outcomes are limited. Children undergoing tonsillectomy to improve number of throat infections, associated health care utilization (clinician visits), and work/school absences had improvements in these outcomes in the first postsurgical year compared with children not receiving surgery. These benefits did not persist over time, and data on longer-term results are lacking. This short-term improvement must be weighed against a roughly 4 percent frequency of PTH.

Byars and others (2018) conducted a population-based cohort study of 1,189,061 children. Subjects included both controls and those who underwent adenoidectomy, tonsillectomy, and adenotonsillectomy in Denmark between 1979 and 1999. Data for these subjects were linked to national registers up to 2009, covering at least the first 10 and up to 30 years of life. There were 17,460 subjects who underwent adenoidectomy, 11,830 who underwent tonsillectomy, and 31,377 who underwent adenotonsillectomy. The control group included 1,157,684 subjects who did not undergo those procedures. The authors reported that “adenoidectomy and tonsillectomy were associated with a 2- to 3-fold increase in diseases of the upper respiratory tract (relative risk [RR], 1.99 and RR, 2.72, respectively).” Smaller increases in risks for infectious and allergic diseases were also found, including that adenotonsillectomy was associated with a 17% increased risk of infectious diseases (RR, 1.17), corresponding to an absolute risk increase of 2.14%. They concluded by suggesting, “It is important to consider long-term risks when making decisions to perform tonsillectomy or adenoidectomy.”

1. National Library of Medicine. Sleep apnea. Available at: https://www.nlm.nih.gov/medlineplus/sleepapnea.html. Accessed on November 7, 2023.
2. National Library of Medicine. Tonsillectomies and children. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001998.htm. Accessed on November 7, 2023.