Frenectomy or Frenotomy for Ankyloglossia

Policy ID: S-9003-02

Section: Surgery

Effective Date: May 01, 2020

Revised Date: December 01, 2020

Revision Effective Date: January 04, 2021

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

Description

Ankyloglossia, or tongue-tie, exists when the inferior lingual frenulum attaches to the bottom of the tongue and restricts its movement. This condition can impair the normal mobility of the tongue and interfere with newborn feeding.

Criteria

Lingual or labial frenectomy, frenotomy, or frenuloplasty is medically necessary for individuals up to two (2) years of age for ankyloglossia when newborn feeding difficulties exist.

Prophylactic frenectomy, frenotomy or frenuloplasty to promote speech development is experimental and investigational because the effectiveness of this approach has not been established.

Procedure Codes

40806

40819

41010

41115

41520

D7961

D7962

D7963

Diagnosis Codes

P92.01

P92.09

P92.1

P92.2

P92.3

P92.4

P92.5

P92.6

P92.8

P92.9

Q38.1

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 New Policy

Internal Medical Policy Committee 11-19-20 Coding Update - Effective January 01, 2021

Added new codes D7961 and D7962 replacing D7960.

Internal Medical Policy Committee 11-23-2021 Annual Review, no changes in the criteria.

Internal Medical Policy Committee 11-29-2022 Annual Review, no changes in the criteria.

Internal Medical Policy Committee 11-15-2023 Annual Review, no changes in the criteria.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.