Commercial
Advanced Search

Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate
11.03.01g

Policy

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

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.

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, ​septoplasty, or septorhinoplasty may be considered a medically necessary component of the reconstructive plan when an 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.

Presurgical appliances for maxillary repair to facilitate palatal expansion in preparation for bone graft surgery of the alveolar cleft and postsurgical 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:
  • Presurgical orthodontics align the maxillary alveolar segments prior to bone graft surgery.
  • Postsurgical 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 ​most 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.

MANDATES


The laws of the state where the group benefit contract is issued determine the mandated coverage.​

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 midfacial 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 9 months and 2 years of age, and may require several stages, including:
  • Presurgical maxillary repair to facilitate palatal expansion in preparation for bone graft surgery of the alveolar cleft
  • Maxillary alveolar bone grafting
  • The use of postsurgical appliances to support bone grafting
RHINOPLASTY, SEPTOPLASTY, SEPTORHINOPLASTY

Rhinoplasty, septoplasty, or a combination of both are sometimes necessary as part of the corrective repair of cleft lip, cleft nose, and/or cleft palate ​to address nasal distortion and reduce the risk of nasal obstruction. Depending on severity, they may be ​performed at the time of the original surgery or at a later or revisional surgery, often when the individual has reached skeletal maturity. If orthognathic surgery is indicated, septorhinoplasty may be undertaken to avoid nasal changes that occur with jaw 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 of care for evaluation and treatment of individuals with cleft lip/palate or other craniofacial conditions. [ACPA Web site]. 2024. Available at: https://acpacares.org/parameters-of-care/. Accessed January 14, 2026.


American Society of Plastic Surgeons (ASPS). Cleft lip and palate repair. [ASPS Web site]. 2026. Available at: http://www.plasticsurgery.org/reconstructive-procedures/cleft-lip-and-palate.html. Accessed January 14, 2026.


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.


González-Melgar S, Martín-Martín C. Analysis and treatment of cleft lip nasal and palate deformity. Acta Otorrinolaringol Esp. 2013;64(5):323-330.


Marks MW, Marks C. Fundamentals of Plastic Surgery. Philadelphia: 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):1331-1338.


New Jersey (NJ) Department of Banking and Insurance (DOBI). New Jersey permanent statutes database. Title 17:48-6: P.L. 2024, ch. 232, and JR10. Corporations and institutions for finance and insurance. [NJ DOBI Web site]. Available at: https://www.nj.gov/dobi/index.html​. Accessed January 14, 2026.​


Park YW, Kwon KJ, Kim MK. Double-layered reconstruction of the nasal floor in complete cleft deformity of the primary palate using superfluous lip tissue. Maxillofac Plast Reconstr Surg. 2015;37(1):35.


Sadhu P. Oronasal fistula in cleft palate surgery. Indian J Plast Surg. 2009;42 Suppl(Suppl):S123-S128.


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

CPT Procedure Code Number(s)
21076, 21079, 21080, 21082, 21083, 21084, 21085, 21087, 30420​, 30460, 30462, 30520​, 30580, 30600, 40700, 40701, 40702, 40720, 40761, 42200, 42205, 42210, 42215, 42220, 42225, 42226, 42227, 42235, 42260, 42280, 42281
ICD - 10 Procedure Code Number(s)
N/A
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

Policy History

Revisions From 11.03.01g:
03/23/2026This version of the policy will become effective 03/23/2026.

Septoplasty and septorhinoplasty were added as medically necessary when a significant impairment associated with a cleft lip/nose/palate impacts nasal function. These procedures are already considered medically necessary under the Dermabrasion of Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty policy (11.16.01).

The following CPT codes have been added to this policy: 
30420, 30520​

Revisions From 11.03.01f:
​03/05/2025
​This policy​ has been reissued in accordance with the Company's annual review process​​.
​07/24/2024
​​This policy​ has been reissued in accordance with the Company's annual review process​.​
03/22/2023
​The policy has been reviewed and reissued to Communicate the Company's continued position on Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate​​.​
​05/18/2022
​This policy has been reissued in accordance with the Company's annual review process​.​​
​11/17/2021
​This policy has been reissued in accordance with the Company's annual review process​.​
12/21/2020This version of the policy will become effective 12/21/2020. This policy has been updated to include additional codes for the surgical repair of complications associated with cleft lip, nose, and/or palate. The following CPT codes have been added to this policy: 

30580, 30600


Revisions From 11.03.01e:
05/22/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate.
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.
3/23/2026
3/23/2026
11.03.01
Medical Policy Bulletin
Commercial
No
Connect with Us

2026 Independence Blue Cross

Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.