Commercial

Medical Policy

Notification

Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)

Notification Issue Date:

The version of this policy will become effective 04/29/2019. The intent of this policy has not changed, although it has been modified to incorporate:

Current peer-reviewed literature on surgical techniques for treatment of ankyloglossia
Addition of frenoplasty to title of policy

Title:

Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)

Policy #:

11.03.05e

Policy

Frenectomy, frenotomy, or frenoplasty 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 for most products of the Company.

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, frenotomy, or frenoplasty 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 lay term "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 is the complete removal of the frenum including its attachment to the underlying bone for the purpose of increasing the mobility of the tongue.

Frenotomy, the simple incision or snipping of the tongue-tie (tongue clipping), is the preferred surgery for babies younger than 1 year of age and can be performed in the newborn nursery or professional provider's office. Frenotomy is the most common procedure for partial ankyloglossia; however, this procedure may result in scarring, an unsatisfactory surgical result, or an actual worsening of the restricted tongue motion.

Frenoplasty (i.e., Z-plasty) is another surgical method used for the revision of the frenulum, using a Z-shaped incision, as a lengthening procedure or to prevent or repair scarring.

References

American Academy of Pediatric Dentistry (AAPD). Management considerations for pediatric oral surgery and oral pathology. The Reference Manual of Pediatric Dentistry. 2023;527-536. Available at: https://www.aapd.org/globalassets/media/policies_guidelines/bp_oralsurgery.pdf. Accessed January 23, 2026.

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.

Baker AR, Carr MM. Surgical treatment of ankyloglossia. Operative Techniques in Otolaryngology. 2015;26:28-32.

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.

Chloe SM, Aby J, Truong MT, et al. The superior labial frenulum in newborns: What is normal? Glob Pediatr Health. 2017;(4)1-6.

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

Devishree, Gujjari SK, Shubhashini PV. Frenectomy: A review with the reports of surgical techniques. J Clin Diagn Res. 2012;6(9):1587-1592.

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 January 23, 2026.

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

Iwanaga J, Takeuchi N, Oskouian RJ, et al. Clinical anatomy of the frenulum of the oral vestibule. Cureus. 2017;9(6):e1410.

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 January 23, 2026.

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.

O'Shea JE, Foster JP, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev. 2017 Mar 11;3:CD011065. DOI10.1002/14651858. Available at: http://www.ncbi.nlm.nih.gov/pubmed/28284020. Accessed January 23, 2026.

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. 01/11/2024. Available at: http://www.cps.ca/en/documents/position/ankyloglossia-breastfeeding. Accessed January 23, 2026.

Schuller DE, Schleuning AJ II. 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. Updated 03/26/2021. Available at: http://emedicine.medscape.com/article/879878-overview. Accessed January 23, 2026.

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. Update 07/26/2023. Available at: http://emedicine.medscape.com/article/837347-overview. Accessed January 23, 2026.

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

CPT Procedure Code Number(s)

41010, 41115, 41520

BENEFIT EXCLUSION

40806, 40819

ICD - 10 Procedure Code Number(s)

N/A

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

D7961 Buccal / labial frenectomy (frenulectomy)

D7962 Lingual frenectomy (frenulectomy)

D7963 Frenuloplasty

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 11.03.05e:

03/04/2026	This policy has been reviewed and reissued to communicate the Company’s continuing position on frenectomy, rrenotomy, or frenoplasty for ankyloglossia (tongue-tie).
05/14/2025	This policy has been reviewed and reissued to communicate the Company’s continuing position on Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie).
03/06/2024	This policy has been reviewed and reissued to communicate the Company’s continuing position on Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie).
04/19/2023	This policy has been reviewed and reissued to communicate the Company’s continuing position on Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie).
06/29/2022	The policy has been reviewed and reissued to communicate the Company’s continuing position on Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie).
03/24/2021	This policy has been reviewed and reissued in accordance with the Company's annual review process.
01/01/2021	This version of the policy will become effective 01/01/20201 The following HCPCS code has been deleted from the policy: D7960 (Benefit Exclusion) The following HCPCS codes has been added from the policy: D7961 & D7962 (Benefit Exclusion)

Revisions From 11.03.05d:

10/07/2020	This policy has been reviewed and reissued in accordance with the Company's annual review process.
04/29/2019	The version of this policy will become effective 04/29/2019. The intent of this policy has not changed, although it has been modified to incorporate: Current peer-reviewed literature on surgical techniques for treatment of ankyloglossia Addition of frenoplasty to title of policy

Revisions From 11.03.05c:

03/28/2018

The 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:

1/1/2021

Version Issued Date:

12/31/2020

Version Reissued Date:

3/4/2026