Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Frenectomy or Frenotomy for Ankylogossia (Tongue-Tie)

Policy #:11.03.05c

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Frenectomy or frenotomy of the lingual frenulum for ankyloglossia is considered medically necessary and, therefore, covered for any of the following symptoms:
  • Difficulty feeding/eating
  • Difficulty chewing (mastication)
  • Difficulty swallowing
  • Speech impairment or difficulty with articulation

Procedures associated with the lingual frenum (other than for ankyloglossia), the labial frenum (i.e., labial frenotomy), and the buccal frenum are always considered dental procedures and never considered medical procedures. Therefore, these procedures are considered benefit contract exclusions.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, frenectomy or frenotomy of the lingual frenulum for ankyloglossia is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Description

Ankyloglossia is the medical term for an abnormally short lingual frenulum (also referred to as frenum), the small band of tissue that attaches the underside of the tongue to the floor of the mouth. This congenital anomaly, described by the layperson as tongue-tie, may impair the normal mobility of the tongue by impeding protrusion and excursion, possibly affecting feeding, chewing, swallowing, and/or speech. The diagnosis of ankyloglossia is not based on an objective anatomical measurement, rather, it is defined by functional ability. The lingual frenum associated with ankyloglossia should not be confused with the labial frenum, which attaches to the center of the upper lip and between the upper two front teeth. The labial frenum can cause gum recession, a large gap in the front teeth, and difficulty with denture placement. The buccal frenum is a fold or band of mucous membrane connecting the alveolar ridge to the cheek and separating the labial vestibule from the buccal vestibule.

Ankyloglossia is uncommon in newborns and, when discovered, it is generally without significant consequence. Most newborns with ankyloglossia breastfeed successfully without medical or surgical intervention. Ankyloglossia does not routinely cause speech impairments or problems with articulation. The current literature suggests that if the tongue is able to touch the anterior dentition (front teeth), adequate mobility exists for the development of normal speech.

Frenectomy (also known as frenulectomy, frenumectomy, or frenotomy), involves the excision of the frenulum for the purpose of increasing the mobility of the tongue. Simple excision of the frenulum (tongue clipping) is adequate for partial ankyloglossia; however, this procedure may result in scarring, an unsatisfactory surgical result, or an actual worsening of the restricted tongue motion. Z-plasty release (using a Z-shaped incision) is another surgical method used for the revision of the frenulum, as a lengthening procedure or to prevent or repair scarring.
References


American Academy of Pediatric Dentistry (AAPD). Guideline on Management Considerations for Pediatric Oral Surgery and Oral Pathology. 2015. Available at: http://www.aapd.org/media/Policies_Guidelines/G_OralSurgery2.pdf. Accessed February 21, 2018.

Aras MH, Göregen M, Güngörmüş M, et al. Comparison of diode laser and Er:YAG lasers in the treatment of ankyloglossia. Photomed Laser Surg. 2010;28(2):173-177.

Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110:e63.

Brookes A, Bowley DM. Tongue tie: The evidence for frenotomy. Early Hum Dev. 2014;90(11):765-768.

Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics. 2011;128(2):280-288.

Chinnadurai S, Francis DO, Epstein RA, et al. Treatment of ankyloglossia for reasons other than breastfeeding: A systematic review. Pediatrics. 2015;135(6):e1467-e1474.

Community Paediatrics Committee. Ankyloglossia and breastfeeding. Canadian Paediatric Society Position Statement. Paediatr Child Health. 2002;7(4):269-270.

Dolberg S, Botzer E, Grunis E, et al. A randomized, prospective, blinded clinical trial with cross-over of frenotomy in ankyloglossia: Effect on breast-feeding difficulties. Pediatr Res. 2002;52(5):822-827.

Dollberg S, Botzer E, Grunis E, et al. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: A randomized, prospective study. J Pediatr Surg. 2006;41(9):1598-1600.

Francis DO, Chinnadurai S, Morad A, et al. Treatments for ankyloglossia and ankyloglossia with concomitant lip-tie. Comparative Effectiveness Reviews, No. 149. Agency for Healthcare Research and Quality: Rockville, MD. Report No.: 15-EHC011-EF. May 2015. Available at: http://www.ncbi.nlm.nih.gov/books/NBK299120/. Accessed February 27, 2017.

Ito Y. Does frenotomy improve breast-feeding difficulties in infants with ankyloglossia? Pediatr Int. 2014;56(4):497-505.

Kotlow LA. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Quintessence Int. 1999;30(4):259-262.

Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: Clinical suggestions for diagnosis and management. Pediatr Dent. 2005;27(1):40-46.

Lalakea ML, Messner AH. Ankyloglossia: Does it matter? Pediatr Clin North Am. 2003;50(2):381-397.

Marmet C, Shell E, Marmet R. Neonatal frenotomy may be necessary to correct breast feeding problems. J Hum Lact. 1990;6(3):117-121.

Masaitis NS, Kaempf JW. Developing a frenotomy policy at one medical center: A case study approach. J Hum Lact. 1996;12(3):229-232.

Messner AH, Lalakea ML. Ankyloglossia: Controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54(2-3):123-131.

Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg. 2002;127:539-545.

Messner AH, Lalakea ML, Aby J, et al. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg. 2000;126:36-39

National Institute for Health and Clinical Excellence (NICE). Division of ankyloglossia (tongue-tie) for breast feeding. Interventional Procedure Guidance 149. London, UK: NICE; December 2005. Available at: https://www.nice.org.uk/guidance/ipg149. Accessed February 21, 2018.

Newkirk GR. Tongue-tie snipping (frenotomy) for ankyloglossia. In: Procedures for Primary Care Physicians. 1st ed. JL Pfenninger, ed,. St Louis, MO: Mosby-Year Book Inc; 1994:287-290.

O'Callahan C, Macary S, Clemente S. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol. 2013;77(5):827-832.

Olivi G, Signore A, Olivi M, Genovese MD. Lingual frenectomy: Functional evaluation and new therapeutical approach. Eur J Paediatr Dent. 2012;13(2):101-106.

Pie-Sanchez J, Espana-Tost AJ, Arnabat-Domínguez J, et al. Comparative study of upper lip frenectomy with the CO2 laser versus the Er, Cr:YSGG laser. Med Oral Patol Oral Cir Bucal. 2012;17(2):e228-e232.

Reddy NR, Marudhappan Y, Devi R, Narang S. Clipping the (tongue) tie. J Indian Soc Periodontol. 2014;18(3):395-398.

Rowan-Legg A, Canadian Paediatrics Society, Community Paediatrics Committee. Position Statement: Ankyloglossia and breastfeeding. May 11, 2015. Available at: http://www.cps.ca/en/documents/position/ankyloglossia-breastfeeding. Accessed February 27, 2017.

Schuller DE, Schleuning II AJ. DeWeese and Saunders' Otolaryngology-Head and Neck Surgery. 8th ed. St. Louis, MO: Mosby; 1994:216-217.

Sclafani AP, Parker AJ. Z-Plasty. [eMedicine Web site]. 11/13/2015. Available at: http://emedicine.medscape.com/article/879878-overview. Accessed February 27, 2017.

Segal LM, Stephenson R, Dawes M, et al. Prevalence, diagnosis, and treatment of ankyloglossia: Methodologic review. Can Fam Physician. 2007;53(6):1027-1033.

Steehler MW, Steehler MK, Harley EH. A retrospective review of frenotomy in neonates and infants with feeding difficulties. Int J Pediatr Otorhinolaryngol. 2012;76(9):1236-1240.

Tewfik TL. Cleft Lip and Palate and Mouth and Pharynx Deformities. [eMedicine Web site]. 04/17/2015. Available at: http://emedicine.medscape.com/article/837347-overview. Accessed February 21, 2018.

Toner D, Giordano T, Handler SD. Office frenotomy for neonates: Resolving dysphagia, parental satisfaction and cost-effectiveness. ORL Head Neck Nurs. 2014;32(2):6-7.

Veyssiere A, Kun-Darbois JD, Paulus C, et al. Diagnosis and management of ankyloglossia in young children. Rev Stomatol Chir Maxillofac Chir Orale. 2015;116(4):215-220.

Webb AN, Hao W, Hong P. The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. Int J Pediatr Otorhinolaryngol. 2013;77(5):635-646.

Wright JE. Tongue-tie. J Paediatr Child Health. 1995;31(4):276-278.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

41010, 41115, 41520

BENEFIT EXCLUSION

40806, 40819


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

SURGICAL TREATMENT OF THE LINGUAL FRENULUM IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODE

Q38.1 Ankyloglossia



HCPCS Level II Code Number(s)

BENEFIT EXCLUSION

D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure

D7963 Frenuloplasty



Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

Revisions 11.03.05c
03/28/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Frenectomy or Frenotomy for Ankylogossia (Tongue-Tie).


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 07/05/2017
Version Issued Date: 07/05/2017
Version Reissued Date: 03/28/2018

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