Tonsillitis: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sinus surgery (bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, frontal sinusotomy, bilateral inferior turbinate reduction, septoplasty, image guidance surgical navigation, and tonsillectomy). The treatment for chronic sinusitis can include a combination of antibiotics, oral steroids, intranasal steroids, irrigations, allergy management, and sinus surgery. In this case, the patient presented with symptoms of chronic sinusitis despite maximal non-surgical management. The patient’s computed tomography (CT) scan was noted to confirm a diagnosis of chronic sinusitis. Endoscopic sinus surgery is reserved for patients with chronic rhinosinusitis who fail medical management. Patients can benefit from surgery to correct an underlying anatomic abnormality and reestablish the sinus drainage.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral tonsillectomy. Current medical literature establishes that patients with recurrent acute tonsilitis experienced significant benefits in throat-related quality of life following tonsillectomy. Clinical studies have shown that tonsillectomies are also a useful tool for adults with sleep apnea. The medical literature indicates that isolated tonsillectomies can be successful as a treatment for adults with obstructive sleep apnea (OSA), especially among patients with large tonsils and mild to moderate OSA. One study showed that tonsillectomies are effective in reducing a patient’s sleepiness scale score and improving swallowing dysfunction. Overall, patients demonstrated nearly an 80% surgical response to treatment, even when performed in an isolated manner.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a tonsillectomy and/or uvulectomy. The indications for adult tonsillectomy have never been explicitly defined by published clinical consensus. Rather, the need for a tonsillectomy has traditionally been extrapolated from the indications for tonsillectomy in children. The two central indications for a tonsillectomy are recurrent tonsillitis and obstructive sleep-disordered breathing which is a clinical inference for obstructive sleep apnea related to tonsillar hypertrophy. A study revealed that the most common indications for tonsillectomy in the adult population, included infection (i.e. tonsillitis), excisional biopsy to rule out malignancy, tonsil stones, and obstructive sleep apnea.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tonsillectomy surgery. Indications for a tonsillectomy include recurrent throat infection with documentation. Clinicians may recommend a tonsillectomy for recurrent throat infection with a frequency of at least seven episodes in the past year; at least five episodes per year for two years; or at least three episodes per year for three years. There should be documentation in the medical records for each episode of sore throat, and documentation of one or more of the following: temperature greater than 38.3 degrees Celsius, cervical adenopathy, tonsillar exudates, or a positive test for Group A Beta-Hemolytic Streptococcal infections (GABHS).

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for tonsillitis was denied, the published record says the denial is worth fighting.