Cleft Palate/Lip Reconstruction

Effective Date: July 01, 2018
Revised Date: November 12, 2019
Last Reviewed: November 14, 2019

Description

Cleft palate is a congenital hole in the roof of the mouth involving the hard or soft palate, or a complete cleft of both palates. A cleft palate interferes with feeding and speech development.

Criteria

Benefits are available for cleft palate/lip reconstruction required to restore bodily function or correct deformity. Reconstruction may be performed in stages.

As part of cleft palate reconstruction, benefits are available under the medical benefit for surgical repair; obturator used to bridge the gap in the roof of the mouth; dental services and appliances, including teeth extraction, orthodontia, bridges or osseointegrated implants to replace congenitally missing teeth.

Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.

Procedure Codes

40700 40701 40702 40720 40761 42200 42205
42210 42215 42220 42225

And any appropriate CPT or HCPCS codes describing the service provided.

Diagnosis Codes

Q35.1 Q35.3 Q35.5 Q35.7 Q35.9 Q37.0 Q37.1
Q37.2 Q37.3 Q37.4 Q37.5 Q37.8 Q37.9