Tonsillectomy

Applies to:

All plans

Definition:

A surgical procedure to remove the tonsils.

Tonsillectomy coverage

Patients must meet InterQual criteria for the service to be covered. Medical necessity considerations will be escalated to our Medical Directors.

Tonsillectomy authorizations

Required for:

Elective pediatric tonsillectomies for patients 0-17 years.

Participating providers: Use the Auth Request tool to request through Clear Coverage™

Non-participating providers: Use the Medical Authorization Request form (PDF)

Not required:

For patients 18 years and older.

Pre-service tonsillectomy education

Pre-service education is recommended for:

  • Group and individual HMO, EPO, POS and PPO plan members
  • Medicaid and Healthy Michigan Plan members

We recommend our members view an Emmi® pre-procedure education video on their procedure. Emmi® programs take complex information and make it easy for a patient and family to understand treatment options and what they can do before, during and after surgery to improve outcomes.

Using Emmi® to facilitate shared decision-making

Once the prior authorization request is approved, Priority Health will send our member an Emmi® video electronically, with a recommendation to view the educational video for the procedure they are considering. The video, "Pediatric Tonsillectomy with Possible Adenoidectomy," can be viewed online or via a smart phone.

To add ordering of the Emmi program to your office workflow

You can order the appropriate program on the Emmi® website.

  1. Click on the link above and enter your patient's information and email address
  2. Click the View Program button
  3. The program will be automatically emailed to your patient for them to complete.

    Note: The program will start automatically and you can just close the browser at this time.

Emmi documents and links