Frenectomy or Frenotomy for Ankyloglossia

Section: Surgery
Effective Date: May 01, 2020
Last Reviewed: March 16, 2020

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

D7960

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

NA

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