CurrentAlaska MedicaidPolicy N/A

Frenectomy (Buccal/Labial D7961; Lingual D7962)

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Defines medical necessity criteria and authorization requirements for buccal/labial and lingual frenectomy services for Alaska Medicaid members; applies to providers performing these dental procedures under Alaska Medicaid.

Policy Summary

PayerAlaska Medicaid

PolicyFrenectomy (Buccal/Labial D7961; Lingual D7962)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization for members six weeks and older; document medical necessity and required photographs in the patient record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D7961,D7962Covered procedure codes referenced

Under 6 wksNo-SA age group

6 wks+SA required age group

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CurrentAlaska MedicaidPolicy N/A

Frenectomy (Buccal/Labial D7961; Lingual D7962)

Customize your policy alerts

Sign up for all Alaska Medicaid policy alerts

Know when Alaska Medicaid releases new policies or updates existing guidance.

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Policy Summary

PayerAlaska Medicaid

PolicyFrenectomy (Buccal/Labial D7961; Lingual D7962)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization for members six weeks and older; document medical necessity and required photographs in the patient record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D7961,D7962Covered procedure codes referenced

Under 6 wksNo-SA age group

6 wks+SA required age group

Photos requiredDocumentation

Coverage and Medical Necessity Criteria

Medical Appropriateness Criteria

Buccal/labial and lingual frenectomies are considered medically appropriate when ALL of the following category- and age-specific criteria are met:

Overall: Procedure must meet the age-specific criteria below and required documentation

Photographs required for all ages; buccal (cheek) frenectomy is not considered medically necessary in any case.

Age Category: Either member under six weeks OR member six weeks and older

Under six weeks: Primary care provider documents medical necessity and rationale in the patient record; service may be performed if urgent to assist with breastfeeding or relieve maternal pain; lingual frenectomy evaluation/diagnosis may occur as early as 5 days old; prior authorization (SA) not required; photographs required.

Member may be responsible for out-of-pocket costs if service is considered optional.

Six weeks and older: Procedure performed by an oral surgeon, periodontist, pediatric dentist, or primary care provider; billed using codes appropriate to provider specialty; prior authorization (SA) required; photographs required; documentation must demonstrate a true-tie and limited tongue range of motion for lingual frenectomy (e.g., unable to touch cheeks sideways and unable to touch edge of lower lip forward) or for labial frenectomy inability of the lip to fold up and touch the nares.

Labial-specific criteria: Indicated for a thick, tight labial frenum that persists in the permanent dentition and can prevent closure of a diastema; not indicated for diastema closure or treatment under age 10; permanent maxillary incisors and canines should be erupted before treatment; may be performed during active orthodontic treatment in the permanent dentition if requested by the orthodontist.

Performing labial frenectomy prior to eruption of permanent maxillary incisors and canines can cause diastema and scar tissue requiring revision.

The policy distinguishes anatomic locations and clinical indications for frenectomy procedures. Buccal (cheek) frenectomy refers to removal of a frenulum located on the sides of the mouth; the policy states explicitly that a buccal/cheek frenectomy is not considered medically necessary in any case. By contrast, labial (lip) and lingual (tongue) frenectomies may be medically appropriate when age- and documentation-specific criteria are met (see criteria for members under six weeks and for members six weeks and older). Labial frenectomy has additional prerequisites related to dentition and timing: it is indicated for a thick, tight labial frenum persisting in the permanent dentition that prevents diastema closure, is not indicated for diastema closure under age 10, and should be deferred until the permanent maxillary incisors and canines have erupted unless performed during active orthodontic treatment at the request of an orthodontist.

Buccal (cheek) frenectomy is not considered medically necessary in any case. Claims for buccal frenectomy will be denied because the policy does not recognize any clinical indication that meets medical necessity for this procedure.

Procedure Coding

Covered CDT CodesCPTCovered

D7961	Buccal/Labial frenectomy (as referenced)
D7962	Lingual frenectomy (as referenced)

Provider Requirements and Authorization

Prior Authorization

Prior authorization (SA) required for members ≥6 weeks; not required <6 weeks

For members six weeks and older, submit a prior authorization (SA) request before performing D7961 or D7962; for members under six weeks SA is not required but primary care must document medical necessity in the patient record. Bill using codes appropriate to the provider specialty (oral surgeon, periodontist, pediatric dentist, or primary care provider).

SA required for members six weeks and older
No SA required for members under six weeks (primary care must document medical necessity)
Bill with provider-appropriate code sets

Step Therapy

Clinical prerequisites: mobility assessment, eruption timing; no step therapy

Confirm clinical prerequisites before authorization or procedure: assess tongue or lip mobility per policy (true‑tie with limited tongue range of motion or labial inability to fold lip to touch the nares). For labial frenectomy, wait until permanent maxillary incisors and canines have erupted and do not perform for diastema closure under age 10. No step therapy is specified.

Background

A frenectomy is a minor dental surgical procedure to remove the frenulum, the small fold of connective tissue that attaches one oral surface to another. It is performed across the lifespan — in infants, children, and adults — to address functional impairment such as restricted tongue or lip mobility and, in infants, to improve breastfeeding. For lingual frenectomy, the policy requires documentation of a true‑tie and limited tongue range of motion (for example, inability to touch the cheeks laterally or the edge of the lower lip forward). For labial frenectomy, the clinical concern is a thick, tight labial frenum that persists in the permanent dentition and prevents diastema closure; timing relative to eruption of permanent maxillary incisors and canines affects appropriateness.

Key Definitions

Frenectomy — definition of surgical removal of frenulum

DefinitionSurgical removal of the frenulum, the small fold of connective tissue membrane that attaches one oral surface to another.

Anatomic sitesFrenula may attach lips, cheeks (buccal), or tongue (lingual) to adjacent oral structures.

Indications (general)Performed across the lifespan (infants, children, adults) to address functional impairment such as limited mobility affecting feeding, speech, or oral hygiene.

Procedure noteProcedure may be performed by appropriate dental or medical providers depending on patient age and clinical need (see age-specific criteria).

True-tie (tongue tie) — definition and functional description

DefinitionA true-tie (tongue tie) is a condition with limited tongue range of motion demonstrated by inability to touch the cheeks when moving sideways and inability to touch the edge of the lower lip when moving forward.

Policy Summary

PayerAlaska Medicaid

PolicyFrenectomy (Buccal/Labial D7961; Lingual D7962)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization for members six weeks and older; document medical necessity and required photographs in the patient record.

SourceLink

On This Page

Lingual: document true‑tie and limited tongue range of motion (unable to touch cheeks sideways and unable to touch edge of lower lip forward)
Labial: lip unable to fold up and touch the nares; indicated only for thick/tight frenum persisting in permanent dentition
Do not perform labial frenectomy for diastema closure under age 10
Permanent maxillary incisors and canines must be erupted before labial frenectomy
No step therapy required

Documentation Required

Required documentation: medical necessity, photographs, age‑specific findings

Document medical necessity and clinical findings in the patient record and include photographs with the evaluation. For members six weeks and older, documentation must show a true‑tie and limited tongue range of motion for lingual procedures; photographs are required for all ages when applicable. For members under six weeks, primary care must document medical necessity in the record.

Document medical necessity and reasoning in patient records
Provide photographs with evaluations (photographs required)
For ≥6 weeks, include evidence of true‑tie and limited tongue range of motion (lingual) or lip unable to fold to touch nares (labial)
For <6 weeks, primary care documentation of medical necessity is required

Denial Risk

Denial triggers: unmet criteria, missing SA/photographs, non‑covered buccal procedures

Claims may be denied if the procedure does not meet policy criteria, required documentation (including SA when applicable and photographs) is missing, or the procedure is a buccal (cheek) frenectomy which is not considered medically necessary in any case.

Buccal (cheek) frenectomy is not considered medically necessary in any case
Denial risk if SA is not obtained for members six weeks and older
Denial risk for labial frenectomy performed before eruption of permanent maxillary incisors/canines or for diastema closure under age 10
Denial risk if required photographs or documentation of medical necessity/clinical findings are missing

Documentation requirementFor members six weeks and older, documentation of a true-tie and limited tongue range of motion is required for lingual frenectomy prior authorization.

Clinical relevanceMay be evaluated as early as 5 days old when urgent treatment is needed to assist breastfeeding or relieve maternal pain.

Associated criteriaLingual frenectomy is subject to age-based authorization rules: SA not required for under six weeks; SA required for six weeks and older and procedure should be performed by appropriate specialists.