ARCHIVED

Medical Policy

Policy Num:     13.008.001
Policy Name:    Frenectomy
Policy ID:          [13.008.001]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:     October 26, 2023
Next Review:     Policy Archived

ARCHIVED
 

Related Policies: None

Frenectomy

Summary

It is the surgical procedure of the extirpation, dissection or muscular liberation of the frenulum that causes ankyloglosia, diastema, problems in; speech phonetics, lactation, poor retention of prostheses and periodontal such as, loss of adherent gingiva.

We have upper lip frenulum, lower lip frenulum, lingual frenulum and lateral maxillary and mandibular frenulum.

Objective

To liberate the frenulum that may cause

      a. Ankyloglosia

      b. Diastemas (insured with orthodontic coverage)

      c. Loss of adherent gingiva ( needs  periodontal coverage)

      d. Lactations problems

      e. Poor retention of prostheses

Policy Statements

1.Requires predetermination.

2.The predetermination must be accompanied by the evaluation and recommendations of the health professional that refers the insured due to the conditions of problems with speech or breastfeeding.

3.It is not recognized for payment for the purpose of closing diastema, except for those coverages that have the benefit of orthodontics.

4.Frenulum that are causing periodontal problems would be covered if have the benefit of periodontal services.

Policy Guidelines

In the Medical policies, CPT codes are covered only for medical conditions when predetermination is accompanied by the evaluation of a health professional. The condition covered is problems with speech and new born babies with breastfeeding problems.

In the Dental policy CDT codes are covered to insured with orthodontic or periodontal coverage. The predetermination is for tooth position problems as diastemas caused by labial frenulum or periodontics problems as recession of gums or other periodontal problems caused by the frenulum.

Benefit Application

BlueCard/National Account Issues - N/A

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Definitions of interest;

Ankyglossia

     Also known as tongue-tie. Is a congenital oral anomaly that decreases the mobility of the tongue tip caused by unusually short, thick lingual frenulum.

Diastema

    Is a space or gab between two teeth (Maxillary incisors), caused by the labial frenulum.

Frenectomy

    Is the surgical procedure of extirpation, dissection or muscular liberation of the frenulum that caused ankyglosia, diastemas, problems in; speech phonetics, lactation, poor retention of prostheses and periodontal such as loss of adherent gingiva.

Frenotomy

   Division of any frenum, especially for tongue tie.

Frenoplasty

          Is the correction of an abnormally attached frenum or frenulum, by surgically repositioning it.

Regulatory Status

N/A

Rationale

Frenectomy is the procedure that detach the frenum that may interfere causing several mouth problems such as, and not limited to; (speech problems, breast feeding limitations, periodontal problems, and tooth position (diastemas).

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American];LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflectiveof and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g.,women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Population Reference No. 1 

Individual: With speech problems caused by lingual frenum. Intervention of interest is: Frenectomy. Comparators of interest: Speech therapy. Relevant outcomes include: Best phonetical and quality of life.

Population Reference No. 2 

Individual: With lactancy problems (caused by buccal or lingual frenum). Intervention of interest is: Frenectomy. Comparators of interest: Bottle feeding. Relevant outcomes include: More intake of milk on new born breast- feeding babies, quality of life, less traumatic for the mother giving breast feeding and breast feeding benefits (nutrition’s and immunes).

Population Reference No. 3 

Individual: With periodontal problem caused by the frenum. Intervention of interest is: Frenectomy. Comparators of interest: No correction of frenum. Relevant outcomes include: Correction of; adherent gingiva, avoid gingival recession and more retention on patients, with removable prosthesis.

Population Reference No. 4 

Individual: With speech problems caused by lingual frenum. Intervention of interest is: Frenectomy. Comparators of interest: Speech therapy. Relevant outcomes include: Best phonetical and quality of life.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Participating Periodontist Manual 2023, Oral and Maxillofacial Surgery; Other Repair Procedures.

2. Participating Oral and Maxillofacial Surgeon Manual 2023, Oral and Maxillofacial Surgery; Other Repair Procedures.

3. Participating Odontopediatric Manual 2023, Oral and Maxillofacial Surgery; Other Repair Procedures.

Codes

Appplicable Modifiers

N/A

Policy History