Tonsillectomy/Adenoidectomy

Transcription

1 Last Review Date: January 12, 2018 Number: MG.MM.SU.58C2 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, ( EmblemHealth ) has adopted the herein policy in providing management, administrative and other services to HIP Health Plan of New York, HIP Insurance Company of New York, Group Health Incorporated and GHI HMO Select, related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Adenoids Tonsils Throat infection Tonsillectomy Sleep-disordered breathing PFAPA 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 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 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 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 increases in severity from primary snoring to obstructive sleep apnea (OSA). Daytime symptoms associated with 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 adenitis. Guidelines A. Adenoidectomy B. Tonsillectomy with or without adenoidectomy

2 Page 2 of 5 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 3 17 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 β-hemolytic streptococcus (GABHS)

3 Page 3 of 5 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: 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: 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: b. OSA diagnosed by polysomnography (See also Obstructive Sleep Apnea Diagnosis and Treatment) 6. Suspicion of tonsillar malignancy Applicable Procedure Codes Tonsillectomy and adenoidectomy; younger than age Tonsillectomy and adenoidectomy; age 12 or over Tonsillectomy, primary or secondary; younger than age Tonsillectomy, primary or secondary; age 12 or over Adenoidectomy, primary; younger than age Adenoidectomy, primary; age 12 or over Adenoidectomy, secondary; younger than age 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

4 Page 4 of 5 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): Au CT, Li AM. Obstructive sleep breathing disorders. Pediatr Clin N Am. 2009; 56(1): 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):S Blakley BW, Magit AE. The role of tonsillectomy in reducing recurrent pharyngitis: a systematic review. Otolaryngol Head Neck Surg. 2009; 140(3): 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): Burton MJ, Pollard AJ, Ramsden JD. Tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA). Cochrane Database Syst Rev. 2010;(9):CD Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in children. Am Fam Physician. 2004; 69(5): , 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): Garavello W, Romagnoli M, Gaini RM. Effectiveness of adenotonsillectomy in PFAPA syndrome: a randomized study. J Pediatr. 2009; 155(2): Lim J, McKean MC. Adenotonsillectomy for obstructive sleep apnoea in children. Cochrane Database Syst Rev. 2009;(2):CD

5 Page 5 of 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): 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): National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancer. V Accessed January 16, 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): 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 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): Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. 2006; 149(6): Van Staaij BK, van den Akker EH, Rovers MM, et al. Effectiveness of adenotonsillectomy in children with mild symptoms of throat infections or adenotonsillar hypertrophy: open, randomised controlled trial. BMJ. 2004; 329