BCBST Tennessee Logo, Plans for Better Health, Plans for a Better Life
UM Guidelines
Pediatric Adenotonsillectomy for Obstructive Sleep Apnea Syndrome (OSAS): Observation Care

Inpatient and Surgical Care (ISC)

BCBST last reviewed December 20, 2017*

Exceptions may be required to comply with EPSDT & BlueCare® regulations.
Observation Care Admission Criteria
  • Observation may be appropriate for a patient 3 years of age or less with a diagnosis of OSAS who has risk factors for postoperative respiratory complications which include 1 or more of the following:
    • Severe OSAS on polysomnography
    • Cardiac complications of OSAS (e.g., right ventricular hypertrophy)
    • Failure to thrive
    • Obesity
    • Prematurity
    • Recent respiratory infection
    • Craniofacial anomalies
    • Neuromuscular disorders. See General Criteria: Observation Care guideline.
Observation Care Discharge Criteria
  • Discharge to nonacute care follow-up is appropriate for a patient with ALL of the following:
    • Procedure is completed
    • Physiologic recovery
    • Stable vital signs
    • Stable respiratory status
    • Patient alert
    • Temperature appropriate
    • Postoperative effects resolved or managed
    • Voiding status acceptable
    • Competent person available to accompany patient
    • No complicating features
  1. American Academy of Pediatrics. (2012, September). Clinical Practice Guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome. Retrieved September 15, 2017 from http://pediatrics.aappublications.org/content/130/3/576.full.pdf.
  2. American Academy of Otolaryngology – Head and Neck Surgery. (2011, August). Clinical Practice Guideline: Tonsillectomy in children. Retrieved August 11, 2011 from  http://oto.sagepub.com/content/144/1_suppl/S1.full.pdf+html.
  3. American Society of Anesthesiologist. (2014, February). Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Retrieved September 7, 2016 from  http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1917935.
  4. BlueCross BlueShield of Tennessee network physicians. September – December 2017.
  5. Pediatrics. (2016, June). Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: Update 2016. Retrieved September 7, 2016 from  http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1212.


Download Acrobat Reader