Clinical UM Guideline

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

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.

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 completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. It may be performed with or without adenoidectomy. The most common indication for tonsillectomy in adults is recurrent acute pharyngitis and chronic tonsillitis. Other indications include infections, sleep-disordered breathing (SBD), suspected malignancy, and IgA nephropathy.

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). The AAO-HNS currently does not have a clinical practice guideline for adults. Although many recommendations for adult tonsillectomy indications are derived from these guidelines for children, published studies have not addressed the generalizability of these pediatric guidelines to adults. Burton and associates produced a systematic review and meta-analysis on tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis (Burton 2014). They found only two trials with low or moderate risk of bias addressing this topic for adults. They concluded that there is insufficient information to form firm conclusions on the effectiveness of these procedures for adults.

Alho and others (2007) conducted a randomized controlled single-center trial to determine the efficacy and safety of tonsillectomy for recurrent streptococcal pharyngitis in adults. The participants included 70 adults with documented recurrent episodes of streptococcal group A pharyngitis who were randomly placed in either a waiting list (control) group (n=34) or immediate tonsillectomy group (n=36). Eligible participants had 3 or more pharyngitis episodes in the previous 6 months or 4 in the previous 12 months. Each episode must have been typical for streptococcal infection and severe enough that the participant sought medical care. Results after 90 days showed 8 participants (24%) in the control group experienced an episode of group A streptococcal pharyngitis while this only occurred in 1 in the tonsillectomy group (21% difference, 95% CI 6% - 36%; NNT 5, 95% CI 3 - 16); 14 participants in the control group experienced an episode of pharyngitis with medical consultation and 4 in the tonsillectomy group (30% difference, 95% CI 11 - 49). Although the generalizability of these results to large populations is limited by the small size and single-center design, this study showed that adult subjects who underwent tonsillectomy were less likely to have recurrent streptococcal pharyngitis and less likely to seek medical consultation for sore throat.

In 2013, Koskenkorva et al. published a non-blinded, randomized, controlled, parallel group, single-center trial with 86 participants 13 years or older referred for tonsillectomy because of recurrent pharyngitis. Subjects were randomly assigned to either a control (watchful waiting) group (n=40) or tonsillectomy group (n=46). The clinical entry criteria for the study were 3 or more episodes of disabling pharyngitis within 12 months. The episodes had to be severe enough for the participants to seek medical attention. The authors reported that 17 participants in the control group (43%) and 2 participants in the tonsillectomy group (4%) consulted a physician for pharyngitis. During a 5-month follow-up, 32 participants in the control group (80%) and 18 participants in the tonsillectomy group (39%) had an episode of pharyngitis. The authors noted that participants in the tonsillectomy group had fewer episodes of pharyngitis and fewer days with sore throat. Lack of blinding may have affected the rates of self-reported symptoms. The small size, short duration of follow-up, and single-center design of this study limit its generalizability to other populations.

A review was completed by Chan et al. in 2001 which included 36 individuals who were admitted with a diagnosis of infectious mononucleosis. Of the 36 individuals, 9 presented with upper airway obstruction and 27 without upper airway obstruction. In the upper airway obstruction group, 8 (89%) underwent tonsillectomy. In the group without upper airway obstruction, 6 (22%) underwent tonsillectomy. The authors noted that tonsillectomy could influence the course of infectious mononucleosis when upper airway obstruction is present, and that tonsillectomy should be considered during the early course of admission.

Amid a rise in severe throat infection-related hospital admissions and a growing emphasis on limiting tonsillectomies, Wilson and colleagues conducted the NAtional Trial of Tonsillectomy IN Adults (NATTINA). It aimed to evaluate if tonsillectomy was indeed an effective and valuable solution for recurrent severe sore throats as compared to non-surgical treatments. The study involved 453 individuals from 27 hospitals who were all 16 years or older and who had experienced 7 or more disabling episodes of sore throat in the previous year, or 5 or more episodes in each of the past 2 years, or 3 or more episodes in the preceeding 3 years. Participants were randomly assigned in a 1:1 ratio to either undergo tonsillectomy or receive conservative management (treatment as needed from their general practitioner). Across a two-year period, weekly text messages were used to track the number of sore throats individuals experienced. Additionally, the impact of sore throats on individuals’ quality of life and their work schedules were assessed. Interviews were also conducted with 47 individuals, general practitioners, and hospital staff to gain their perspectives. Findings revealed that individuals in the tonsillectomy group typically experienced 23 days of sore throat, as compared to 30 days in the conservative management group. Tonsillectomy also led to an improved quality of life.  Interviews showed a high degree of satisfaction among participants who had had tonsillectomies. This relatively large study conducted at multiple sites showed that participants treated with tonsillectomy experienced fewer sore throat days over a 24-month period than similar participants who did not undergo tonsillectomy. (Wilson, 2023)

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder affecting at least 2% to 4% of the adult population. According to the American Academy of Sleep Medicine (AASM), the diagnosis of OSA is confirmed if the number of obstructive sleep events on polysomnography is greater than 15 events/hour or greater than 5/hour in individuals who report any of the following: unintentional sleep episodes during wakefulness; daytime sleepiness; unrefreshing sleep; fatigue; insomnia; waking up breath holding, gasping, or choking; or the bed partner describing loud snoring, breathing interruptions, or both during the individual’s sleep.

The frequency of obstructive events is reported as an apnea + hypopnea index (AHI) or respiratory disturbance index (RDI). AASM defines the severity of OSA as following:

• Mild OSA: AHI or RDI of 5-15;
• Moderate OSA: AHI or RDI of 15-30;
• Severe OSA: AHI or RDI of more than 30.

AAO-HNS position statement on the treatment of obstructive sleep apnea indicates tonsillectomy alone has shown to be effective in adults with enlarged tonsils.

Senchak and colleagues (2015) conducted a prospective multi-institutional study assessing adults with tonsillar hypertrophy scheduled to undergo tonsillectomy alone. The study included 19 participants with OSA. All participants were male ≥ 18 years of age with tonsil size 2 to 4 and body mass index (BMI) of 29.9 ± 6.0. Before surgery, the AHI ranged from 5.4 to 56.4 events per hour. After surgery, the mean AHI decreased from 18.0 to 3.2 evens per hour, a reduction of 82%. Every participant had a lower AHI after the procedure. The researchers concluded adult tonsillectomy alone has beneficial effect in the treatment of OSA, especially in young overweight men with large tonsils and moderate sleep apnea.

In 2016, Camacho et al. completed a systematic review and meta-analysis to determine if AHI and lowest oxygenation saturation improved following tonsillectomy for adult OSA. Of the resulting searches, 47 studies were potentially relevant. Reduced AHI after tonsillectomy was demonstrated in 17 studies (203 participants). The pooled mean AHI fell from a mean ± standard deviations of 40.5 ± 28.9 to 14.1 ± 17.1 events per hour (65% decrease). The authors noted isolated tonsillectomy could be successful for treatment in adults with large tonsils and mild to moderate OSA.

IgA Nephropathy

Immunoglobulin A (IgA) is an antibody made by the immune system to protect the body from foreign substances. IgA nephropathy is a kidney disease that occurs when deposits of the protein immunoglobulin (IgA) builds up inside the kidney.

Kawamura and colleagues (2014) completed a multicenter randomized controlled trial to evaluate the effect of tonsillectomy in individuals with biopsy-proven IgA nephropathy, proteinuria, and low serum creatinine. Individuals were randomly assigned to tonsillectomy with steroid pulses (Group A; n=35) or steroid pulses only (Group B; n=39). During the 12 months from baseline, the percentage decrease in urinary protein excretion was larger in Group A than in Group B (coefficient estimate -1.316, 95% confidence interval [CI], -2.617 to -0.015; p=0.047). Researchers concluded that tonsillectomy combined with steroid pulses produced similar rates of remission of IgA nephropathy compared to treatment with steroid pulses alone.

In 2016, a multicenter, randomized, controlled trial completed by Katafuchi et al. analyzed the effects of tonsillectomy with steroid pulses therapy versus steroid pulses therapy alone in subjects with IgA nephropathy. A total of 59 subjects were included in the study and randomly allocated into tonsillectomy with steroid pulses therapy (Group A; n=26) or steroid pulses therapy alone (Group B; n=33). The subjects in Group A had a 6.75-fold (95% CI, 1.32-34.6) greater benefit of the disappearance of proteinuria than in Group B.

A retrospective cohort study was conducted by Hirano and colleagues in 2019. The study included 1065 individuals over 18 years of age and were diagnosed with IgA nephropathy by renal biopsy between 2002 and 2004. The participants were divided into 2 groups, those who underwent tonsillectomy (n = 252) and those who did not (n = 813). The authors noted significantly better renal survival in individuals in the tonsillectomy group than in the without-tonsillectomy group (HR, 0.34; 95%CI, 0.13-0.77; P = .009). The association between tonsillectomy and reduced risk of the outcome was also observed in an inverse treatment probability weighted model, as well as throughout the entire group of participants. This remained the case as the authors used two larger sample sizes from this same group. Tonsillectomy correlated with a decreased need for additional treatments one year after renal biopsy, both in the cohort matched 1:1 (HR, 0.36; 95%CI, 0.17-0.71; P = .003) and throughout the overall study group (adjusted HR, 0.37; 95%CI, 0.20-0.63; P < .001). The findings of this study need to be confirmed in a prospective randomized trial.

Suspected Malignancy

After thyroid and larynx carcinoma, tonsillar carcinoma is the third most common head and neck malignancy. Theodoraki and colleagues (2017) completed a systematic review of the literature and recommends bilateral tonsillectomy for adults with unilateral tonsillar carcinoma or in cases where the primary cancer is unknown.

Sunkaraneni et al. (2006) conducted a retrospective case-note review of all tonsillectomies performed for histological examination at one facility over a 5-year period and reviewed the histological findings in those with unilateral tonsillar enlargement alone and those with unilateral tonsillar enlargement with other clinical features. The other clinical features included chronic pain, dysphagia, the presence of tonsillar or peritonsillar mucosal abnormality, and cervical lymphadenopathy. There were 53 individuals who had unilateral tonsillar enlargement, 33 had unilateral tonsillar enlargement alone and 20 had other clinical features. In the unilateral tonsillar enlargement alone group, none of the individuals were found to have malignancy. In the group with other clinical findings, 9 (45%) individuals had a malignancy. The authors concluded that, for individuals with unilateral tonsil enlargement, a ‘watch and wait’ policy is initially appropriate for a period of up to 6  weeks. If signs or symptoms progress or are consistent with malignancy, tonsillectomy should then be advised.

Other Considerations

For tonsillectomy for psoriasis, the evidence is insufficient and additional research is recommended. Thorleifsdottir and colleagues conducted a randomized controlled trial to analyze the effects of tonsillectomy on individuals with streptococcal-associated psoriasis exacerbations. A total of 29 individuals were randomly assigned to tonsillectomy (n=15) or control (n=14) and were followed for 24 months. The Psoriasis Disability Index (PDI) and Psoriasis Life Stress Inventory (PLSI) were used at 12 and 24 months to assess the individual’s health related quality of life (HRQoL). A positive connection was noted between increased HRQoL and clinical improvement (r=0.297, p=0.008). Researchers noted that more robust trials and long-term follow-up of tonsillectomized individuals with plaque psoriasis is needed.

Apnea-Hypopnea index (AHI) or Respiratory Disturbance index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep.

Cervical adenopathy: Enlargement of the cervical lymph nodes, located on both sides of the neck.

Group A β-hemolytic streptococcus (GABHS): A bacteria commonly associated with serious throat infections in children.

Infectious mononucleosis: An infection usually caused by the Epstein-Barr virus that often occur in teens and young adults with symptoms including fever, sore throat, and swollen lymph glands.

IgA Nephropathy: A chronic kidney disease that occurs when deposits of the protein immunoglobulin (IgA) builds up inside the filters in the kidney.

Obstructive sleep apnea (OSA): A condition that is characterized by cessation of breathing during sleep, caused by temporary collapse of the upper airway.

Pharyngitis: The medical term for a “sore throat.”

Polysomnography: Also known as a “sleep study.” A test used to diagnose sleep disorders.

Tonsils: 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.

Peer Reviewed Publications:

1. Alho OP, Koivunen P, Penna T, Teppo H, Koskela M, Luotonen J. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomized controlled trial. BMJ. 2007 May 5; 334(7600):939.
2. Camacho M, Li D, Kawai M, et al. Tonsillectomy for adult obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. 2016 Sep; 126(9):2176-2186.
3. Chan SC, Dawes PJ. The management of severe infectious mononucleosis tonsillitis and upper airway obstruction. J Laryngol Otol. 2001 Dec; 115(12):973-977.
4. Ferguson M, Aydin M, Mickel J. Halitosis and the tonsils: a review of management. Otolaryngol Head Neck Surg. 2014 Oct; 151(4):567-574.
5. Hirano K, Matsuzaki K, Yasuda T, et al. Association Between Tonsillectomy and Outcomes in Patients With Immunoglobulin A Nephropathy. JAMA Netw Open. 2019 May 3;2(5):e194772.
6. Katafuchi R, Kawamura T, Joh K, et al; IgA nephropathy Study Group in Japan. Pathological sub-analysis of a multicenter randomized controlled trial of tonsillectomy combined with steroid pulse therapy versus steroid pulse monotherapy in patients with immunoglobulin A nephropathy. Clin Exp Nephrol. 2016 Apr; 20(2):244-252.
7. Kawamura T, Yoshimura M, Miyazaki Y, et al; Special IgA Nephropathy Study Group. A multicenter randomized controlled trial of tonsillectomy combined with steroid pulse therapy in patients with immunoglobulin A nephropathy. Nephrol Dial Transplant. 2014 Aug; 29(8):1546-1553.
8. Koskenkorva T, Koivunen P, Koskela M, et al. Short-term outcomes of tonsillectomy in adult patients with recurrent pharyngitis: a randomized controlled trial. CMAJ. 2013 May 14;185(8):E331-6.
9. Lescanne E, Chiron B, Constant I, et al. Pediatric tonsillectomy: clinical practice guidelines. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Oct; 129(5):264-271.
10. Randall DA. Current indications for tonsillectomy and adenoidectomy. J Am Board Fam Med. 2020 Nov-Dec; 33(6):1025-1030.
11. Sunkaraneni VS, Jones SE, Prasai A, et al. Is unilateral tonsillar enlargement alone an indication for tonsillectomy? J Laryngol Otol. 2006 Jul; 120(7):E21.
12. Senchak AJ, McKinlay AJ, Acevedo J, et al. The effect of tonsillectomy alone in adult obstructive sleep apnea. Otolaryngol Head Neck Surg. 2015 May; 152(5):969-973.
13. Theodoraki MN, Veit JA, Hoffmann TK, Greve J. Synchronous bilateral tonsil carcinoma: case presentation and review of the literature. Infect Agent Cancer. 2017 Jun 26; 12:38.
14. Thorleifsdottir RH, Sigurdardottir SL, Sigurgeirsson B, et al. Patient-reported outcomes and clinical response in patients with moderate-to-severe plaque psoriasis treated with tonsillectomy: a randomized controlled trial. Acta Derm Venereol. 2017 Mar 10; 97(3):340-345.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Otolaryngology - Head and Neck Surgery. Position Statement: Treatment of Obstructive Sleep Apnea. April 22, 2021. Available at: https://www.entnet.org/resource/position-statement-treatment-of-obstructive-sleep-apnea/. Accessed June 17, 2024.
2. Burton MJ, Glasziou PP, Chong LY, et al. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014 Nov 19;2014(11):CD001802.
3. Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in children. Am Fam Physician. 2004; 69(5):1147-1154, 1159-1160.
4. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009; 5(3):263-276. Available at: http://www.aasmnet.org/Resources/ClinicalGuidelines/OSA_Adults.pdf. Accessed on June 17, 2024.
5. Mitchell RB, Archer SM, Ishman SL, et al.; American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2019; 160(1S):S1-S42.
6. NCCN Clinical Practice Guidelines in Oncology^TM (NCCN). © 2024 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website at: http://www.nccn.org/index.asp. Accessed on June 17, 2024.
   • Head and Neck Cancer (V4.2024). Revised May 1, 2024.
7. Wilson JA, Fouweather T, Stocken DD, et al. Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation. Health Technol Assess. 2023 Dec;27(31):1-195.

1. National Institute of Diabetes and Digestive and Kidney Disease. IgA Nephropathy. Available at: https://www.niddk.nih.gov/health-information/kidney-disease/iga-nephropathy. Updated September 2022. Accessed on June 17, 2024.
2. National Library of Medicine. Infectious Mononucleosis. Available at: https://medlineplus.gov/infectiousmononucleosis.html. Accessed on June 17, 2024.
3. National Library of Medicine. Sleep apnea. Available at: https://www.nlm.nih.gov/medlineplus/sleepapnea.html. Accessed on June 17, 2024.

Obstructive sleep apnea
Sleep disordered breathing
Tonsillectomy

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

© CPT Only – American Medical Association