Print

Date Printed: October 20, 2017: 02:03 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-40000-25

Original Effective Date: 03/15/15

Reviewed: 03/24/16

Revised: 08/15/17

Subject: Frenectomy or Frenotomy for Ankyloglossia (Tongue-Tie)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
           
   
           

DESCRIPTION:

The lingual frenum is the small band of tissue connecting the tongue to the floor of the mouth. Ankyloglossia, also known as “tongue-tie”, is a congenital condition in newborns and children caused by a frenum of the tongue that is abnormally short or is attached too close to the tip of the tongue. Ankyloglossia can impair the normal movement of the tongue and interfere with speech or newborn feeding.

This condition may be surgically corrected, often as an office procedure in neonates, by simple excision (i.e. frenectomy, frenotomy). Older children require division or excision of the frenulum to be performed in the operating room because the frenulum is thicker and more vascular, requiring surgical correction that includes simple division either with or without a Z-plasty repair.

POSITION STATEMENT:

Lingual frenectomy, lingual frenotomy (i.e., frenulectomy), frenum incision/excision, or frenoplasty to treat ankyloglossia meets the definition of medical necessity when newborn feeding difficulties or childhood and adolescent articulation problems are present.

BILLING/CODING INFORMATION:

CPT Coding:

40806

Incision of labial frenum (frenotomy)

40819

Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)

41010

Incision of lingual frenum (frenotomy)

41115

Excision of lingual frenum (frenectomy)

41520

Frenoplasty (surgical revision of frenum, e.g., with Z-plasty)

ICD-10 Diagnoses Codes That Support Medical Necessity:

Q18.9

Congenital malformation of face and neck, unspecified

Q38.1

Ankyloglossia (tongue tie)

Q38.6

Other congenital malformations of mouth

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Ankyloglossia: a severe restriction of tongue movement as a result of fusion or adherence of the tongue to the floor of the mouth. Partial ankyloglossia (also called tongue-tie) is caused by a frenum of the tongue that is abnormally short or is attached too close to the tip of the tongue; this condition may be surgically corrected by simple excision. Complete ankyloglossia requires extensive surgical reconstruction of the tongue and the floor of the mouth.

Buccal frenum: a fold or band of mucous membrane connecting the alveolar ridge to the cheek and separating the labial vestibule from the buccal vestibule.

Frenum, lingual (frenulum): the vertical band of oral mucosa connecting the tongue with the floor of the oral cavity and the alveolar or residual alveolar ridge.

Frenectomy: surgical excision of a frenum (frenulum).

Frenoplasty, frenuloplasty: surgical correction of an abnormally attached frenum.

Frenotomy: a surgical procedure for repairing a defective frenum, such as the cutting or lengthening of the lingual frenum to correct ankyloglossia.

Labial frenum: Folds of mucous membrane extending from gingiva to midline of lower and upper lips, respectively.

Lingual: pertaining to or near the tongue; also referred to as glossal.

RELATED GUIDELINES:

None

OTHER:

None

REFERENCES:

  1. American Academy of Pediatric Dentistry Clinical Guidelines. Guideline on Pediatric Oral Surgery. Council on Clinical Affairs. Adopted 2005, Revised 2010, 2014. Accessed 12/01/14.
  2. American Academy of Pediatric Dentistry, Guideline on Management Considerations for Pediatric Oral Surgery and Oral Pathology, Council on Clinical Affairs; revised 2015. Accessed at aapd.org 02/26/16.
  3. Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics. 2011 Aug;128(2):280-8. PMID: 21768318.
  4. Devishree, et al. Frenectomy: A Review with the Reports of Surgical Techniques. Journal of Clinical and Diagnostic Research. 2012 November, Vol-6(9): 1587-1592.
  5. Emond, et al: Randomised controlled trial of early frenotomy in breastfed infants with mildmoderate tongue-tie, Archive of Disease in Childhood, Neonatal Ed., 99(3): F189-195, 2014
  6. Francis DO, et al, Treatments for Ankyloglossia and Ankyloglossia With Concomitant Lip-Tie, Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 May. Report No.: 15-EHC011-EF.
  7. National Institute for Health and Clinical Excellence (NICE) interventional procedure guidance 149. Division of ankyloglossia (tongue-tie) for breastfeeding. Issued: December 2005. Accessed 12/01/14.
  8. Rowan-Legg A, Ankyloglossia and Breastfeeding; Paediatr Child Health. 2015 May; 20(4): 209–213.
  9. Segal, et al: Prevalence, diagnosis, and treatment of ankyloglossia: methodologic review, Canadian Family Physician, 53(6): 1027-1033, 2007.
  10. U.S. Food and Drug Administration (FDA) 2001 approval of Waterlase™.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/24/16.

GUIDELINE UPDATE INFORMATION:

03/15/15

New Medical Coverage Guideline; formatting changes.

11/01/15

Revision: ICD-9 Codes deleted.

04/15/16

Annual review; position statement section, coding, and references updated; formatting changes.

10/01/16

Revision; formatting changes.

08/15/17

Revision; coding section updated.

Date Printed: October 20, 2017: 02:03 PM