Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Blue Cross and Blue Shield of Montana (BCBSMT) may consider laser assisted tonsillectomy, as a single-stage alternative to standard tonsillectomy, medically necessary.
BCBSMT considers cryptolysis or subtotal laser assisted tonsillectomy experimental, investigational and unproven.
Because laser assisted tonsillectomy is not considered a multi-stage procedure, reimbursement will only be recognized for one laser assisted tonsillectomy procedure for a member, performed as an alternative to standard tonsillectomy.
When used as a surgical tool in an otherwise conventional tonsillectomy procedure, no data are available to suggest that the use of a laser is associated with an improved outcome; data do suggest, however, that the use of a laser is, in fact, associated with increased postoperative pain. No additional data were found regarding the use of a laser to perform a tonsillectomy in a series of ablative procedures, and no data were available regarding the role of a subtotal tonsillectomy. It is likely that research interest has refocused on the use of radiofrequency tissue volume reduction as a technique for performing submucosal ablation of tonsillar tissue.
One study was a randomized within-subject double-blind comparison of tonsillectomy performed with laser, blunt dissection, electrocautery, or radiofrequency coblation. For each of the 60 adult patients, tonsillectomy was performed with coblation on one randomly chosen side; for the other tonsil one of the other three “standard” techniques was used (20 patients per comparison group). Pain ratings were higher for laser and electrocautery than for blunt dissection and coblation. Both operative time and blood loss were higher for laser (20 minutes and 20 mL, respectively) than coblation (10 minutes and 2.5 mL). Laser and electrocautery resulted in more histopathological thermal tissue injury than coblation. Healing, determined by a blinded evaluator, was slower for electrocautery, but similar for blunt dissection, laser, and coblation. No evidence was found to suggest that use of a laser improves health outcomes in comparison with other methods.
Guidance from the United Kingdom’s National Institute for Health and Clinical Excellence considers safety and efficacy data to be adequate to support the use of laser-assisted tonsillectomy. Efficacy data indicate slower wound healing and increased pain between 24 hours and two weeks after surgery compared with cold-steel dissection. It was also noted that although intraoperative blood loss may be less, the risk of postoperative hemorrhage may be greater. There is also a risk of damage to the patient’s face and upper airway.
One study prospectively compared partial laser assisted tonsillectomy (tonsillotomy) with blunt dissection tonsillectomy in 113 children. The authors noted that a randomized study could not be conducted since (in Germany) tonsillotomy is strictly contraindicated in patients with recurrent throat infections. Therefore, children who had obstructive problems (snoring, sleep apnea, mouth breathing, and eating problems; n=49) and no history of infection were treated with tonsillotomy, while those who had recurrent tonsillitis (n=64) underwent tonsillectomy with blunt dissection. For the tonsillotomy group, no postoperative hemorrhage occurred; the mean time to discharge was three days (range: 1–6). In the tonsillectomy group, 3 (5%) children had postoperative hemorrhage; the time to discharge was 6.9 days (range: 5–12). Follow-up contact was achieved for parents of 40 children (82%) in the tonsillotomy group. Two of the 40 (5%) had regrowth of tonsillar tissue and required a subsequent tonsillectomy; none of the children with tonsillotomy were reported to have had recurrent tonsillitis (average: 16 months; range: 6 to 24 months). Follow-up contact was achieved for parents of 57 children (89%) in the tonsillectomy group, who only reported on postoperative analgesic use. Additional studies with longer follow-up are needed to evaluate rates of postoperative hemorrhage, regrowth, and recurrent tonsillitis with partial tonsillectomy.
A search of peer reviewed literature through May 2011 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.