Patients with the following are exempt from this policy and immediate referral for treatment is recommended:
This procedure will be funded for the treatment of sore throats in adults and children if the following criteria can be met:
- Sore throats are due to acute tonsillitis
- Episodes of sore throats are disabling and prevent normal functioning (documented absence from school or work)
- Seven or more documented, clinically significant, adequately treated sore throats in the previous year* OR five or more such episodes in each of the preceding two years*OR three or more such episodes in each of the preceding three years* (Paradise Criteria) OR severe recurrent tonsillitis in adults that results in two or more hospital admissions.
*Each of the episodes must of a debilitating nature (for example documented absence from school or work >3 days + visit to GP) and be well documented in the patient’s notes.
Detailed documentation of the criteria that are fulfilled is required in the GP’s referral letter, where available; clinically appropriate referrals will be sent to the GPs.
Tonsillectomy for sleep disordered breathing due to obstructive sleep apnoea syndrome (OSAS) in children (<16 years)
Norfolk and Waveney CCGs will fund treatment of OSAS in children if the following criteria can be met:
1. There is a strong history suggestive of obstructive sleep apnoea such as witnessed obstructive apnoea, difficulty breathing whilst asleep, sleeping in an unusual position (with head extended), secondary enuresis, frequent daytime mouth breathing and behavioural or concentration problems. With documented evidence of significant impact on quality of life (for example behavioural or concentration problems, failure to thrive, slowing of weight gain)
2. Clinical diagnosis of obstructive sleep apnoea by a designated ENT consultant with documented clinical features such as adenotonsillar hypertrophy and mouth breathing, with or without evidence of desaturation from a sleep study.
The clinic letter should indicate the evidence that has been evaluated to indicate a significant impact on quality of life (e.g. GP letter, secondary care clinical examination by secondary care consultant, letter from school, sleep study results).
Tonsillectomy is not routinely funded for the treatment of sleep apnoea in adults.
Tonsillectomy will not be funded as a treatment for snoring
Tonsillectomy for pathological airway (type 2) halitosis due to chronic caseous tonsillitis (CCT) with tonsilloliths.
This procedure will be funded for the treatment of severe airway (Type 2) halitosis due to CCT if the following criteria can be met:
1) Pathological halitosis (offensive smelling breath) which has been demonstrated to be due to CCT with tonsil crypt debris (tonsilloliths) with diagnosis confirmed by ENT specialist
2) CCT has not responded to medical management over a period of three months. Medical management can include irrigation, saline gargling, topical antiseptic spray, anti-inflammatories.
Cases for Individual Consideration
On a case to case basis, patients might be eligible for surgical intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request.