CurrentGeisinger Health PlanPolicy MP285

Tonsillectomy

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Defines medical necessity criteria, coding, and coverage stance for tonsillectomy (with or without concurrent procedures) for Geisinger Health Plan members across applicable lines of business.

Policy Summary

PayerGeisinger Health Plan

PolicyTonsillectomy

Policy CodePolicy MP285

Change TypeNo material changes

Effective DateJan 14, 2014

Next Review DateJan 18, 2024

Key ActionObtain and document required clinical evidence (episode frequency and qualifying features or diagnostic PSG results) and verify prior authorization requirements per member contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5primary indications listed

AHI >1.0 / ≥5PSG thresholds

8informational CPTs

Commercial/Medicare/Medicaidlines of business

Medical Necessity and Coverage Criteria

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CurrentGeisinger Health PlanPolicy MP285

Tonsillectomy

Customize your policy alerts

Sign up for Geisinger Health Plan Policy MP285 alerts

Get alerted when Policy MP285 changes without checking for updates manually.

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Defines medical necessity criteria, coding, and coverage stance for tonsillectomy (with or without concurrent procedures) for Geisinger Health Plan members across applicable lines of business.

Policy Summary

PayerGeisinger Health Plan

PolicyTonsillectomy

Policy CodePolicy MP285

Change TypeNo material changes

Effective DateJan 14, 2014

Next Review DateJan 18, 2024

Key ActionObtain and document required clinical evidence (episode frequency and qualifying features or diagnostic PSG results) and verify prior authorization requirements per member contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5primary indications listed

AHI >1.0 / ≥5PSG thresholds

8informational CPTs

Commercial/Medicare/Medicaidlines of business

Medical Necessity and Coverage Criteria

Medically Necessary Indications

Tonsillectomy may be considered medically necessary when ANY of the following indication groups are satisfied with required documentation:

Group A: Recurrent tonsillitis: Medical record documentation of frequent episodes of tonsillitis defined as: seven or more tonsillar infections within the previous year; OR five or more tonsillar infections per year in the previous 2 years; OR three or more tonsillar infections per year in the previous 3 years; AND documentation for each episode of at least one qualifying feature (temperature >38.3°C [100.94°F], cervical adenopathy, tonsillar exudates or erythema, or positive test for Group A β-hemolytic streptococcus).≥7 in prior year OR ≥5/year for 2 years OR ≥3/year for 3 years

Medical record must document at least one qualifying feature per episode (fever >38.3°C, cervical adenopathy, tonsillar exudate/erythema, or positive GABHS).

Group B: Recurrent throat infections with supportive factors: History of recurrent throat infections not meeting Group A frequency thresholds but with additional documented factors that support tonsillectomy (examples include multiple antibiotic allergy/intolerance, PFAPA syndrome, or peritonsillar/parapharyngeal abscess).n/a

The supporting factor must be documented in the medical record.

Group C: Asymmetrical tonsillar enlargement: Asymmetrical tonsillar enlargement with clinical suspicion of potential neoplasm.n/a

Physical exam findings and clinical suspicion for neoplasm must be documented.

Group D: Tonsillar hypertrophy with symptomatic airway obstruction (SDB): Tonsillar hypertrophy documented by physical exam with symptomatic airway obstruction; symptoms must be chronic (>3 months) with sleep-disordered breathing (eg, snoring, mouth breathing, pauses in breathing) AND one of: (1) a condition related to SDB likely to improve after tonsillectomy (eg, growth retardation, poor school performance, enuresis, behavioral problems); OR (2) child <3 years with >3 months symptoms plus caregiver report of regular nocturnal choking/gasping/apnea/breath holding; OR (3) obstructive sleep apnea diagnosed by polysomnogram meeting AHI thresholds (AHI >1.0 for children <12 years; AHI ≥5 for persons ≥12 years).AHI >1.0 (<12 yrs) or AHI ≥5 (≥12 yrs) where PSG is used

Document chronicity (>3 months), SDB signs/symptoms, and which of the listed qualifying conditions is present.

Group E: Concurrent procedures: Tonsillectomy proposed concurrently with adenoidectomy in children when any of criteria 1–4 is met; or tonsillectomy proposed concurrently with uvulopalatopharyngoplasty in adults.n/a

Documentation must justify the concurrent procedure and show that indication criteria for tonsillectomy are met.

Coverage for experimental or investigational treatments, services, and procedures is excluded under the member certificate with Geisinger Health Plan. Unproven services provided outside an approved clinical trial are also specifically excluded. This policy does not expand coverage to services or items that are specifically excluded in the member’s certificate; see MP015 for additional information on experimental, investigational, and unproven services.

Procedures that do not have medical record documentation meeting the criteria outlined in this policy, or that are not covered by the member’s specific benefit plan, may be considered not medically necessary and may be denied. Inclusion of procedure codes in this policy is for informational purposes only and does not guarantee coverage or reimbursement. Eligibility, contract-specific benefits, limitations, and exclusions in the member’s line-of-business benefit document supersede this policy; for Medicare members, applicable LCDs and NCDs will supersede the policy.

Procedure Codes and Clinical Thresholds

Informational Procedure CPT CodesCPT

42820	tonsillectomy and adenoidectomy younger than age 12
42821	tonsillectomy, primary or secondary, age 12 and over
42825	tonsillectomy (listed in doc)
42826	tonsillectomy, age 12 and over
42830	adenoidectomy, primary, younger than age 12
42831	adenoidectomy, age 12 and over
42835	adenoidectomy, secondary, younger than age 12
42836	adenoidectomy, age 12 and over

Recurrent tonsillitis frequency thresholds

Frequency thresholdsSeven or more tonsillar infections within the previous year; OR five or more per year in the previous 2 years; OR three or more per year in the previous 3 years.

Episode documentation requiredFor each episode, medical record must document at least one qualifying feature (fever >38.3°C; cervical adenopathy; tonsillar exudates or erythema; or positive Group A β-hemolytic streptococcus).

ApplicationThresholds apply to determination of medical necessity for recurrent tonsillitis as an indication for tonsillectomy.

Polysomnography AHI thresholds

Children (<12 years)Apnea‑Hypopnea Index (AHI) greater than 1.0 when diagnosed by polysomnogram.

Adolescents/Adults (≥12 years)Apnea‑Hypopnea Index (AHI) of 5 or greater when diagnosed by polysomnogram.

ContextAHI thresholds are used when obstructive sleep apnea is diagnosed by polysomnography to support tonsillectomy for tonsillar hypertrophy with SDB.

Provider Requirements and Administrative Actions

Prior Authorization

Prior authorization may be required

Prior authorization and/or pre-certification requirements may apply for the listed tonsillectomy and related procedure codes; providers should consult the member's contract-specific benefit document and the Geisinger prior authorization site for current requirements before scheduling services.

Prior authorization information available at: https://www.geisinger.org/health-plan/providers/ghp-clinical-policies
Inclusion of codes in the policy does not guarantee coverage; check member contract for precert lists and PA requirements

Step Therapy

Medicaid case-by-case review

For Medicaid Business Segment members, any request that does not meet the policy criteria may be evaluated on a case-by-case basis according to Medicaid business segment processes; follow the Medicaid PARP review workflow when submitting such requests.

Requests failing to meet criteria may still be reviewed and considered under Medicaid case‑by‑case procedures

Documentation Required

Required clinical documentation

Document the frequency of tonsillitis episodes and the qualifying clinical features for each episode in the medical record to support medical necessity.

Frequency thresholds: ≥7 in the previous year, or ≥5 per year for 2 years, or ≥3 per year for 3 years
For each episode document at least one qualifying feature: temperature >38.3°C, cervical adenopathy, tonsillar exudate/erythema, or positive Group A β‑hemolytic streptococcus (GABHS)
If indicating obstructive symptoms, document chronicity (>3 months), SDB features (snoring, mouth breathing, pauses) and, if used, polysomnogram AHI values

Denial Risk

Coverage conditional on benefits and Medicare rules

Coverage is determined by the member-specific benefit document and applicable laws; inclusion of CPT/HCPCS codes in this policy does not guarantee coverage and Medicare LCDs/NCDs will supersede this policy where applicable.

Verify eligibility, contract-specific benefits, limitations and exclusions prior to authorizing or billing
For Medicare members consult CMS or the local Medicare Administrative Contractor for coverage and coding requirements

Tonsillectomy

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Medical Necessity and Coverage Criteria

Tonsillectomy

Sign up for Geisinger Health Plan Policy MP285 alerts

Medical Necessity and Coverage Criteria

Procedure Codes and Clinical Thresholds

Provider Requirements and Administrative Actions

Background

Definitions