Frenectomy or Frenotomy for Ankyloglossia

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FRENECTOMY OR FRENOTOMY FOR ANKYLOGLOSSIA HS-232

Clinical Coverage Guideline page 1 Original Effective Date: 11/7/2013 - Revised: 11/6/2014, 11/5/2015, 11/3/2016, 9/7/2017

Easy Choice Health Plan Harmony Health Plan of Illinois Missouri Care

‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona

Staywell of Florida

WellCare (Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Louisiana, Mississippi, Nebraska, New Jersey, New York, South Carolina, Tennessee, Texas)

WellCare Prescription Insurance

Frenectomy or Frenotomy for Ankyloglossia

Policy Number: HS-232 Original Effective Date: 11/7/2013

Revised Date(s): 11/6/2014; 11/5/2015;

11/3/2016; 9/7/2017

APPLICATION STATEMENT

The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

DISCLAIMER

The Clinical Coverage Guideline (CCG) is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this CCG. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the CCG. Additionally, CCGs relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the CCG is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. All links are current at time of approval by the Medical Policy Committee (MPC). Lines of business (LOB) are subject to change without notice; current LOBs can be found at www.wellcare.com – select the Provider tab, then

“Tools” and “Clinical Guidelines”.

BACKGROUND

Ankyloglossia (tongue-tie) develops when the inferior lingual frenulum attaches to the bottom of the tongue and restricts its movement. This results in the normal mobility of the tongue and interferes with newborn feeding or speech. When this occurs and the inferior lingual frenulum significantly impedes tongue excursion, a frenulectomy may be necessary. The National Institute for Health and Clinical Excellence found that “current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue-tie) and limited evidence suggests that this procedure can improve breastfeeding”.¹Aras et al.² compared the tolerance of lingual frenectomy with regard to a local anesthesia requirement as well as post-surgical discomfort experienced by patients operated on with diode laser or erbium:yttrium-aluminium-garnet (Er:YAG) laser. The study included 16 patients with tongue mobility issues. The conclusion of the study shows that findings indicate that only the Er:YAG laser can be used for lingual frenectomy without local anesthesia. Further no difference was found between the two groups regarding the

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FRENECTOMY OR FRENOTOMY FOR ANKYLOGLOSSIA HS-232

degree of the post-surgical discomfort except in the first 3 hrs. The authors state that the Er:YAG laser is more advantageous than the diode laser in minor soft-tissue surgery as it can be performed without local anesthesia and with only topical anesthesia.

Buryk et al.³ found that ankyloglossia is associated with a variety of infant-feeding problems and that frenotomy commonly is performed for relief of ankyloglossia. The randomized, single-blinded, controlled trial was conducted to decide whether frenotomy for infants with ankyloglossia improved maternal nipple pain and ability to breastfeed.

The investigators found an strong improvement in nipple-pain and breastfeeding scores, despite a placebo effect on nipple pain, which they state provides convincing evidence for those seeking a frenotomy for infants with significant ankyloglossia. Frenectomy or frenotomy for ankyloglossia is most commonly performed in infants. There is a lack of scientific evidence to establish the correlation between ankyloglossia and speech disorders.^4,5 Ankyloglossia may interfere with a child’s articulation, however, there is no evidence to state that ankyloglossia prevents or delays a child’s speech (Kupietzky & Botzer, 2004). The American Academy of Pediatric Dentistry Council on Clinical Affairs note that studies have shown a difference in treatment recommendations among speech pathologists, pediatricians, otolaryngologists, lactation specialists, surgeons, and dental specialists. Most professionals, however, will agree that there are certain indications for these procedures.⁴

POSITION STATEMENT Applicable To:

Medicaid – All Markets Exclusions

All other indications are considered experimental / investigational and not medically necessary.

Coverage

Inferior lingual frenectomy or lingual frenotomy for ankyloglossia is considered medically necessary and a covered benefit when newborn feeding difficulties or childhood articulation problems exist.

CODING

Covered CPT®* Codes

41010 Incision of lingual frenum (frenotomy) 41115 Excision of lingual frenum (frenectomy)

HCPCS®* Codes – No applicable codes.

CPT/HCPCS Modifiers – No applicable codes.

Covered ICD-10-PCS Codes

OCN70ZZ Release tongue, open approach

OCN73ZZ Release tongue, percutaneous approach OCN7XZZ Release tongue, external approach Covered ICD-10-CM Diagnosis Codes

Q38.1 Ankyloglossia (Tongue tie)

P92.5 Neonatal difficulty in feeding of breast R47.89 Other speech disturbances

Non-Covered ICD-10-CM Diagnosis Codes – All other indications non-covered.

REFERENCES

1. Division of ankyloglossia (tongue-tie) for breast feeding: interventional procedure guidance 149. National Institute for Health and Clinical

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FRENECTOMY OR FRENOTOMY FOR ANKYLOGLOSSIA HS-232

Excellence (NICE) Web site.https://www.nice.org.uk/guidance/ipg149. Published 2005. Accessed August 8, 2017.

2. Aras, M.H., Göregen, M., GüngörmüÅŸ, M., & Akgül, H.M. (2010). Comparison of diode laser and Er:YAG lasers in the treatment of ankyloglossia. Photomedicine and Laser Surgery, 28(2), 173-177.

3. Buryk, M., Bloom, D., & Shope, T. (2011). Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics, 128(2), 280-288.

4. American Academy of Pediatric Dentistry Council on Clinical Affairs. (2010). Guideline on pediatric oral surgery. American Academy of Pediatric Dentistry, 35(6), 268-275.

5. Kupietzky, A., & Botzer, E. (2004). Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management.

Pediatric Dentistry, 27(1), 40-46.

MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS

Date Action

9/7/2017  Approved by MPC. No Changes.

11/3/2016  Approved by MPC. Removal of ICD-9 codes only.

11/5/2015  Approved by MPC. Coding changes only.

11/6/2014  Approved by MPC. No changes to content; coding change only.

11/7/2013  Approved by MPC. New.