Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate

Policy #:11.03.01e

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. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

REPAIR OF CLEFT LIP, CLEFT NOSE, AND/OR CLEFT PALATE

The surgical repair of a cleft lip, cleft nose, and/or cleft palate is considered medically necessary and, therefore, covered to correct a congenital defect.
  • The surgical repair plan may consist of serial surgeries as part of a reconstructive plan to achieve optimal functional outcomes; these surgeries may be considered medically necessary and, therefore, covered.
  • Rhinoplasty may be considered a medically necessary component of the reconstructive plan when individual has a significant impairment of nasal function.

In exceptional circumstances of marked deformity resulting from severe congenital anomaly (e.g., atypical clefts, a bilateral cleft lip and alveolus that separates the philtrum of the upper lip and premaxilla from the rest of the maxillary arch), the surgical repair of a cleft lip, cleft nose, and/or cleft palate performed in the absence of additional serial surgeries as part of a reconstructive plan may be considered medically necessary and therefore covered. Photographs demonstrating the deformity may be required to determine coverage.

Pre-surgical appliances for maxillary repair to facilitate palatal expansion in preparation for bone graft surgery of the alveolar cleft and post-surgical appliances to support bone grafting are considered medically necessary and, therefore, covered under the medical benefit of the Company's products for cleft lip, cleft nose, and/or cleft palate repair.

Appliances provided pre- or post-repair of the cleft lip, cleft nose, and/or cleft palate typically consist of two phases, both of which are covered under the medical benefit of the Company's products:
  • Pre-surgical orthodontics align the maxillary alveolar segments prior to bone graft surgery.
  • Post-surgical orthodontics support the bone graft and keep the maxillary alveolar segments in the desired position until the grafts have stabilized.

Replacement of appliances required for cleft lip, cleft nose, and/or cleft palate repair is covered under the medical benefit of the Company's products when the replacement is due to the growth of the individual.

The surgical repair of a cleft lip, cleft nose, and/or cleft palate performed solely to change the appearance of any portion of the face, without the expectation of improving physiologic functioning is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Orthodontic services performed to align permanent dentition (i.e., braces) are not covered under the medical benefit of the Company's products.

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 health care professional'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

The treatment of congenital birth anomalies of newborn children is a mandated benefit for members in Pennsylvania, Delaware, and New Jersey, and is covered under the medical benefits of the Company's products for 31 days after birth. After 31 days, the infant must be enrolled as a dependent child in order to be covered under the medical benefits of the Company's products.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, repair of cleft lip, cleft nose, and/or cleft palate with or without rhinoplasty is covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

Orthodontic services performed to align permanent dentition (i.e., braces) are not covered under the medical benefit of the Company's products.

Description

Cleft lip, cleft nose, and cleft palate are congenital defects in which a fissure or elongated opening separates the upper lip, nose, and/or palate, thus forming a communicating passageway between the mouth and the nasal cavities. Cleft lip, cleft nose, and cleft palate can occur singly or in combination, with varying degrees of complexity. They can be unilateral or bilateral, and incomplete or complete. Therefore, the surgical repair plan is individualized and may consist of a single surgery or a series of surgeries. Cleft lip and cleft palate generally have associated defects of the nose as well. These may include smaller and misshapen cartilage on one or both sides of the nose, which may obstruct the airway. The nasal septum generally has a significant deviation or deflection and the inner lining of the nose is often deficient and tight.

Repair of defects from these conditions are critical to meet the individual's nutritional needs and facilitate emerging expressive language skills. There is agreement in the medical literature that a long delay in repair is not prudent because postponement may produce less-than-optimal functional and aesthetic outcomes. Delayed repair can also result in facial asymmetry due to retarded growth and/or disturbed mid-facial development. Moreover, postponement in correction may contribute to other problems, such as reduced senses of taste and smell, and hearing loss due to recurrent auditory canal infections, which are a direct result of palatal clefts. Additionally, it has been observed that significant numbers of infants with cleft lip, cleft nose, and/or cleft palate develop maxillary hypoplasia, which may require orthognathic surgical correction; therefore, surgical treatment of the defect may occur when the facial bones are still growing.

REPAIR OF CLEFT LIP (CHEILOPLASTY) AND/OR CLEFT NOSE

This surgical repair is typically performed immediately after birth or in early infancy (6-12 weeks of age). Nostril deformities, which are often present with cleft lips, can be improved at the time of the cheiloplasty or at a later surgery.

REPAIR OF CLEFT PALATE (PALATOPLASTY)

This surgical repair is typically performed between nine months and two years of age, and may require several stages, including:
  • Pre-surgical maxillary repair to facilitate palatal expansion in preparation for bone graft surgery of the alveolar cleft
  • Maxillary alveolar bone grafting
  • The use of post-surgical appliances to support bone grafting

RHINOPLASTY

A surgical procedure to reshape the nose, rhinoplasty is sometimes necessary as part of the corrective repair of cleft lip, cleft nose, and/or cleft palate. Rhinoplasty may be provided at the time of the original surgery or at a later or revisional surgery.

REVISIONAL SURGERY

Typically, as part of a reconstructive plan, the defects of cleft lip, cleft nose, and/or cleft palate are repaired by the time the child has reached adulthood, but there may be circumstances where revisional surgeries may be required after the individual has reached adulthood. Revisional surgeries consist of serial surgeries as part of the reconstructive plan, and are generally performed to improve function.

COSMETIC

Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.
References


American Cleft Palate-Craniofacial Association (ACPA). Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. [ACPA Web site]. November 2009. Available at: http://www.acpa-cpf.org/uploads/site/Parameters_Rev_2009.pdf. Accessed March 20, 2017.

American Society of Plastic Surgeons (ASPS). Cleft lip and palate repair. [ASPS Web site]. 2017. Available at:
http://www.plasticsurgery.org/reconstructive-procedures/cleft-lip-and-palate.html. Accessed March 20, 2017.

Anastassov GE, Joos U, Zollner B. Evaluation of the results of delayed rhinoplasty in cleft lip and palate patients. Functional and aesthetic implications and factors that affect successful nasal repair. Br J Oral Maxillofac Surg. 1998;36(6):416-424.

Behrman R, Kliegman R, Arvin A. Nelson's Textbook of Pediatrics. 15th ed. Philadelphia, PA: WB Saunders Company; 1996:1041-1042.

Georgiade GS, Riefkohl R, Levin LS. Plastic, Maxillofacial, and Reconstructive Surgery. 3rd ed. Baltimore, MD: Williams and Wilkins; 1997:230-257.

Gonzalez-Melgar S, Martin-Martin C. Analysis and treatment of cleft lip nasal and palate deformity. Acta Otorrinolaringol Esp. 2013. [Epub ahead of print].

March of Dimes. Professionals and Researchers. Cleft lip and cleft palate. [March of Dimes Web site]. January 2017. Available at: http://www.marchofdimes.com/baby/cleft-lip-and-cleft-palate.aspx. Accessed March 20, 2017.

Marks MW, Marks C. Fundamentals of Plastic Surgery. Philadelphia, PA: WB Saunders Company; 1997:155-173.

Millard DR, Latham R, Huifen X, et al. Cleft lip and palate treated by presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (POPLA) compared with previous lip adhesion method: a preliminary study of serial dental casts. Plast Reconstr Surg. 1999;103(6):1630-1644.

Millard DR, Morovic CG. Primary unilateral cleft nose correction: a 10-year follow-up. Plast Reconstr Surg. 1998;102(5):1331-8.

National Conference of State Legislatures (NCSL). Mandated health insurance benefits and state laws. [NCSL Web site]. December 2015. Available at:http://www.ncsl.org/issues-research/health/mandated-health-insurance-benefits-and-state-laws.aspx. Accessed March 20, 2017.

New Jersey (NJ) Department of Banking and Insurance (DOBI). New Jersey permanant statutes database. Title 17:48-6: P.L. 2011, ch. 232, and JR10. Corporations and institutions for finance and insurance. [NJ DOBI Web site]. Available at:
http://lis.njleg.state.nj.us/cgi-bin/om_isapi.dll?clientID=30373870&Depth=2&TD=WRAP&advquery=congenital&depth=4&expandheadings=on&headingswithhits=on&hitsperheading=on&infobase=statutes.nfo&rank=&record={705C}&softpage=Doc_Frame_PG42&wordsaroundhits=2&x=23&y=22&zz=. Accessed March 20, 2017.

Smahel Z, Mullerova Z, Nejedly A. Effect of primary repositioning of the nasal septum on facial growth in unilateral cleft lip and palate. Cleft Palate Craniofac J. 1999;36(4):310-313.

Steinberg B, Padwa BL, Boyne P, Kaban L. State of the art in oral and maxillofacial surgery: Treatment of maxillary hypoplasia and anterior palatal and alveolar clefts. Cleft Palate Craniofac J. 1999;36(4):283-291.





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)

21076, 21079, 21080, 21082, 21083, 21084, 21085, 21087, 30460, 30462, 40700, 40701, 40702, 40720, 40761, 42200, 42205, 42210, 42215, 42220, 42225, 42226, 42227, 42235, 42260, 42280, 42281


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)

Q30.2 Fissured, notched and cleft nose

Q35.1 Cleft hard palate

Q35.3 Cleft soft palate

Q35.5 Cleft hard palate with cleft soft palate

Q35.7 Cleft uvula

Q35.9 Cleft palate, unspecified

Q36.0 Cleft lip, bilateral

Q36.1 Cleft lip, median

Q36.9 Cleft lip, unilateral

Q37.0 Cleft hard palate with bilateral cleft lip

Q37.1 Cleft hard palate with unilateral cleft lip

Q37.2 Cleft soft palate with bilateral cleft lip

Q37.3 Cleft soft palate with unilateral cleft lip

Q37.4 Cleft hard and soft palate with bilateral cleft lip

Q37.5 Cleft hard and soft palate with unilateral cleft lip

Q37.8 Unspecified cleft palate with bilateral cleft lip

Q37.9 Unspecified cleft palate with unilateral cleft lip



HCPCS Level II Code Number(s)



D5931 Obturator prosthesis, surgical

D5932 Obturator prosthesis, definitive

D5933 Obturator prosthesis, modification

D5936 Obturator prosthesis, interim

D5954 Palatal augmentation prosthesis

D5955 Palatal lift prosthesis, definitive

D5958 Palatal lift prosthesis, interim

D5959 Palatal lift prosthesis, modification

D5992 Adjust maxillofacial prosthetic appliance, by report

D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.03.01e:
08/01/2018This policy has been reissued in accordance with the Company's annual review process.


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

Version Effective Date: 06/16/2017
Version Issued Date: 06/16/2017
Version Reissued Date: 08/02/2018

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.