Tonsillectomy, Adenoidectomy, Adenotonsillectomy


	UM Guidelines

Inpatient and Surgical Care (ISC)

BCBST modification effective June 26, 2008*

Deleted from: Clinical Indications

Milliman Care Guidelines Clinical Indications were deleted.

Added to: Clinical Indications

Indicated for any one of the following:

Patient with three (3) or more infections of tonsils and/or adenoids per year despite adequate medical therapy.*

Hypertrophy causing dental malocclusion or adversely affecting orofacial growth documented by an orthodontist.**

Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications.**

Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon, unless surgery performed during acute stage.

Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy.

Chronic or recurrent tonsillitis associated with the streptococcal carrier state and not responding to beta - lactamase - resistant antibiotics.

Unilateral tonsil hypertrophy presumed neoplastic.

Recurrent suppurative or otitis media with effusion (Adenoidectomy alone, tonsillectomy added requires one of the indications listed above).

Sources

American Academy of Otolaryngology-Head and Neck Surgery. (2000). Clinical indicators tonsillectomy, adenoidectomy, adenotonsillectomy. Retrieved May 3, 2006 from http://www.entlink.net/practice/products/indicators/tonsillectomy.html.

American Academy of Otolaryngology - Head and Neck Surgery. (2000). Clinical indicators adenoidectomy. Retrieved May 3, 2006 from http://www.entlink.net/practice/products/indicators/adenoidectomy.html.

BlueCross BlueShield of Tennessee network physicians. April - June 2008.

Footnotes

Reprinted with the permission of the American Academy of Otolaryngology – Head and Neck Surgery from Bulletin 2000 Clinical Indicators Compendium.

*For infectious conditions, it is recommended that there be information regarding dates of last two infections, description of fever, severity of discomfort, information about throat cultures, use of antibiotics, and history of otitis media management.

** For hypertrophy or noninfectious conditions it is recommended that history include information regarding growth and weight gain, any medical conditions necessitating removal of tonsils and adenoids, and polysomnography (optional) including hourly number of apnea or hypopnea episodes.

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines. The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material. Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.

	Deleted from: Clinical Indications


	Milliman Care Guidelines Clinical Indications were deleted.

	Added to: Clinical Indications


	Indicated for any one of the following: Patient with three (3) or more infections of tonsils and/or adenoids per year despite adequate medical therapy.* Hypertrophy causing dental malocclusion or adversely affecting orofacial growth documented by an orthodontist. Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications. Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon, unless surgery performed during acute stage. Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy. Chronic or recurrent tonsillitis associated with the streptococcal carrier state and not responding to beta - lactamase - resistant antibiotics. Unilateral tonsil hypertrophy presumed neoplastic. Recurrent suppurative or otitis media with effusion (Adenoidectomy alone, tonsillectomy added requires one of the indications listed above). Sources American Academy of Otolaryngology-Head and Neck Surgery. (2000). Clinical indicators tonsillectomy, adenoidectomy, adenotonsillectomy. Retrieved May 3, 2006 from http://www.entlink.net/practice/products/indicators/tonsillectomy.html. American Academy of Otolaryngology - Head and Neck Surgery. (2000). Clinical indicators adenoidectomy. Retrieved May 3, 2006 from http://www.entlink.net/practice/products/indicators/adenoidectomy.html. BlueCross BlueShield of Tennessee network physicians. April - June 2008. Footnotes Reprinted with the permission of the American Academy of Otolaryngology – Head and Neck Surgery from Bulletin 2000 Clinical Indicators Compendium. For infectious conditions, it is recommended that there be information regarding dates of last two infections, description of fever, severity of discomfort, information about throat cultures, use of antibiotics, and history of otitis media management. * For hypertrophy or noninfectious conditions it is recommended that history include information regarding growth and weight gain, any medical conditions necessitating removal of tonsils and adenoids, and polysomnography (optional) including hourly number of apnea or hypopnea episodes.