BlueCross and BlueShield of Montana Medical Policy/Codes
Laser Assisted Tonsillectomy
Chapter: Surgery: Procedures
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: August 26, 2013
Description

Traditionally, tonsillectomy has been performed by means of “cold” dissection.  The tonsil and its capsule are separated from the surrounding tissues using metal instruments (i.e., scissors, snare, or knife).  The upper pole of the tonsil is mobilized then dissection continues to the base of the tongue.

A laser-assisted tonsillectomy may describe any of the following procedures:

  • The use of a laser as a surgical tool in an otherwise standard tonsillectomy procedure;
  • The use of the laser to sequentially vaporize the tonsils in a series of outpatient visits; and
  • The use of the laser to vaporize the surface of the tonsils, i.e.,  cryptolysis or subtotal tonsillectomy.

Either a hand-held carbon dioxide laser (Acupulse® 30 and 40, Lumenis, Inc., Santa Clara, CA), a potassium-titanyl-phosphate laser (KTP/532), diode laser (Quanta System Diode Medical Laser System®, Quanta System SpA, Olona VA, Italy), or an ND:YAG long pulse laser (NaturaLase LP® Laser, Focus Medical, Bethel, CT) may be used.

Policy

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.

Medically Necessary

Blue Cross and Blue Shield of Montana (BCBSMT) may consider laser assisted tonsillectomy, as a single-stage alternative to standard tonsillectomy, medically necessary.

Investigational

BCBSMT considers cryptolysis or subtotal laser assisted tonsillectomy experimental, investigational and unproven.

Policy Guidelines

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.

Rationale

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.

Partial Tonsillectomy

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. 

2011 Update

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.

Coding

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. 

ICD-9 Codes
28.2, 29.3, 034.0, 146.0, 210.5, 327.20, 327.23, 327.29, 463, 472.0, 472.1, 473.0, 473.1, 473.2, 473.8, 474.00, 474.01, 474.02, 474.10, 474.11, 474.12, 474.2, 474.8, 474.9, 475, 478.19, 519.8, 780.51, 780.53, 780.57, 780.59, 786.09, V12.69
Procedural Codes: 42825, 42826
References
  1. Auf, I.., Osborne, J.E., et al.  Is the KTP laser effective in tonsillectomy? Clinical Otolaryngologica (1997) 22(2):145-6.
  2. Nelson, L.M.  Radiofrequency treatment for obstructive tonsillary hypertrophy.  Archive of Otolaryngoogical and Head Neck Surgery (2000) 126(6):736-40.
  3. Helling, K., Abrams, J., et al.  Laser tonsillectomy in tonsiller hyperplasia of early childhood.  European Archives of Oto-Rhino-Laryngology (2002 May) 50(5):470-8.
  4. Kothari, P., Patel, S., et al.  A prospective double-blind randomized controlled trial comparing the suitability of KTP laser tonsillectomy with conventional dissection tonsillectomy for day case surgery.  Clinical Otolaryngology and Allied Science (2002 October) 27(5):369-73.
  5. Jackel, M.C., Petzold, S., et al.  Tonsillectomy by C0² laser microsurgery—an analysis of clinical and morphological data.  European Archives of Oto-Rhino-Laryngology (2003 August) 51(8):634-9.
  6. Remacle, M., Keghian, J., et al.  Carbon-dioxide laser-assisted tonsil ablation for adults with chronic tonsillitis: a 6-month follow-up study (2003 September) 260(8):456-9.
  7. Passos, C.A., Altemani, A., et al.  Histopathological evaluation in biopsies of palatine tonsils submitted to cryptolysis by coagulation with C0² laser for treatment of chronic caseous tonsillitis. Photo med Laser Surgery (2004 June) 22(3):211-9.
  8. Unkel, C., Lehnerdt, G., et al.  Long-term results of laser-tonsillotomy in obstructive tonsillar hyperplasia.  Laryngo- Rhono- Otologie (2004 July) 83(7):466-9.
  9. Gunzel, T., Zenev, E., et al.  Postoperative bleeding after tonsillectomy between 1985 and 2001 and experiences to perform laser tonsillotomy.  Laryngo- Rhino- Otologie (2004 September) 83(9):579-84.
  10. Andrews, P.J., Latif, A.  Outpatient laser tonsillar ablation under local anaesthetic. European Archives of Oto-Rhino-Laryngology (2004 November) 261(10):551-4. 
  11. D’Eredita, R., Marsh, R.R.  Contact diode laser tonsillectomy in children.  Otolaryngology and Head and Neck Surgery (2004 November) 131(5):732-5.
  12. Hagedorn, H., Andratschke, M.  Tonsillectomy versus laser tonsillotomy for tonsillar hyperplasia in children.  MMW Fortschr Med (2005 April 28) 147(17):45-6, 49.
  13. Laser Assisted Tonsillectomy.  Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2005 January) Surgery 7.01.56. 
  14. Scott, A.  Hot techniques for tonsillectomy.  Issues of Emergency Health Technology (2006 November) 122(3):282-90.
  15. National Institute for Health and Clinical Science.  Tonsillectomy using laser. Accessible at http://www.nice.org.uk . Issued (2006 July) Accessed (2011 June 16).
  16. Reichel, O., Mayr, D., et al.  Tonsillotomy or tonsillectomy?—a prospective study comparing histological and immunological findings in recurrent tonsillitis and tonsillar hyperplasia.  European Archives of Oto-Thino-Laryngology (2007 March) 264(3):277-84.
  17. Laser Assisted Tonsillectomy.  Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2008 February) Surgery 7.01.56. 
  18. Magdy, E.A., Elwany, S., et al.  Coblation tonsillectomy: a prospective, double-blind, randomized clinical and histopathological comparison with dissection-ligation, monopolar electrocautery and laser tonsillectomies.  Journal of Laryngology and Otology (2008 March) 122(3):282-90.
  19. Hegazy, H.M., Albirmawy, O.A., et al.  Pilot comparison between potassium titanyl phosphate laser and bipolar radiofrequency in paediatric tonsillectomy.  J Laryngol Otol (2008) 122(4):369-73.
  20. Laser Assisted Tonsillectomy.  Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2009 March) Surgery 7.01.56-A.
History
August 2013  New 2013 BCBSMT medical policy.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Laser Assisted Tonsillectomy