CG-SURG-36 Adenoidectomy

This policy addresses adenoidectomy (surgical removal of the adenoids). It is covered when there is suspected adenoid tumor based on imaging or endoscopy; chronic adenoiditis with rhinorrhea persisting ≥12 weeks despite ≥3 weeks of appropriate antibiotics; or chronic rhinosinusitis ≥12 weeks despite ≥3 weeks of antibiotics with corroborating findings (e.g., CT evidence of obstruction/infection, significant disease on nasal endoscopy, or physical exam findings such as mucopurulence, erythema, edema). It is not covered for other indications, including use in children under 4 years for acute or recurrent otitis media; documentation of symptom duration, prior antibiotic therapy, and objective findings is required.

"Adenoidectomy is consideredmedically necessaryfor individuals when any of the following conditions are met:"

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