Frenectomy / Frenuloplasty
DESCRIPTION
Developmental structural anomalies in the oral mucosa and tongue can result in functional limitations with feeding and swallowing, speech, malocclusion, and potential periodontal problems. The most common anomaly, ankyloglossia or tongue-tie is characterized by a short, thick lingual frenulum, limiting the movement of the tongue. During breastfeeding, this can cause ineffective latch, inadequate milk transfer, and maternal nipple pain, adversely affecting feeding and swallowing. Speech pathology also has been associated with ankyloglossia.
A high or prominent maxillary frenulum is often associated with diastema. This can result in a traumatic force on the gingival tissue or can prevent the diastema from resolving after eruption of the permanent canines. Treatment should be delayed until the permanent incisors and cuspids have erupted. This allows the diastema to close naturally. A high labial aspect of the mandibular ridge, most often in the central incisor area, can lead to food and plaque accumulation. Early treatment may be indicated to prevent subsequent inflammation, recession, pocket formation, and possible loss of the alveolar bone and/or tooth.
Frenectomy/frenuloplasty involves the surgical clipping or resection of the frenulum and may be a treatment option for functional limitations, following a thorough pediatric evaluation.
POLICY
Frenectomy/frenuloplasty for the treatment of oral structural anomalies is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Frenectomy/frenuloplasty for the treatment of oral structural anomalies is considered medically appropriate if ALL of the following criteria are met:
The individual has undergone a pediatric evaluation
ANY ONE of the following are met:
Functional limitations resulting in inadequate feeding or swallowing
Limited tongue mobility resulting in speech disorders, following completion of evaluation and therapy by a qualified speech pathologist
Class III malocclusion affecting skeletal development, following completion of a comprehensive orthodontic workup, diagnosis, and treatment plan
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
American Academy of Pediatric Dentistry. (2010). Guideline on pediatric oral surgery. Retrieved June 7, 2011 from http://www.aapd.org/media/Policies_Guidelines/G_OralSurgery.pdf.
Amir, L. H., James, J. P., & Donath, S. M. (2006). Reliability of the Hazelbaker assessment tool for lingual frenulum function. International Breastfeeding Journal, 1 (1), 3. (Level 3 Evidence - Independent study)
Complete Guide to Medicare Coverage Issues [Computer software]. (2011, April). Dental services (Section 150, p. 4-246). Ingenix.
Complete Guide to Medicare Coverage Issues [Computer software]. (2011, April). Dental services exclusion (Section 140, p. 4-318). Ingenix.
Geddes, D. T., Langton, D. B., Gollow, I., Jacobs, L. A., Hartmann, P. E., & Simmer, K. (2008). Frenulotomy for breastfeeding infants with ankyloglossia: Effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics, 122 (1), e188-e194. (Level 4 Evidence - Industry sponsored)
Mueller, D. T. & Callanan, V. P. (2007). Congenital malformations of the oral cavity. Otolaryngologic Clinics of North America, 40 (1), 141-160.
National Guideline Clearinghouse. (2010). Guideline on adolescent oral health care. Retrieved June 9, 2011 from http://www.guidelines.gov.
National Guideline Clearinghouse. (2010). Guideline on Pediatricoral surgery. Retrieved June 9, 2011 from http://www.guidelines.gov.
Segal, L. M., Stephenson, R., Dawes, M., & Feldman, P. (2007). Prevalence, diagnosis, and treatment of ankyloglossia: Methodologic review. Canadian Family Physician, 53 (6), 1027-1033.
U. S. Food and Drug Administration. (2007, October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K072262. Retrieved June 9, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf7/K072262.pdf.
ORIGINAL EFFECTIVE DATE: 6/10/2006
MOST RECENT REVIEW DATE: 7/14/2011
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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