CurrentAlliance HealthPolicy 1A-16

Surgery of the Lingual Frenulum (frenectomy/frenotomy/frenuloplasty)

North Carolina Medicaid clinical coverage policy that defines medical necessity criteria, prior approval, provider billing and coding, and limitations for surgery of the lingual frenulum (ankyloglossia). Applies statewide to NC Medicaid beneficiaries, includes EPSDT provisions for beneficiaries under 21.

Policy Summary

PayerAlliance Health

PolicySurgery of the Lingual Frenulum (frenectomy/frenotomy/frenuloplasty)

Policy CodePolicy 1A-16

Change TypeClarified prior approval agetemplate and organizational edits

Effective DateJan 1, 1974

Next Review Date

Key ActionObtain prior approval before performing surgery of the lingual frenulum for beneficiaries aged 2 years and older and submit supporting records showing the beneficiary meets Section 3.2 criteria.

SourceLink

POLICY UPDATE CHANGES

Prior approval age threshold clarified from 'over 1 year of age' to '2 years of age and older' (09/01/2024).

Definitions previously in subsection 5.2.2 were moved to Section 1.0 and updated (09/01/2024).

Administrative/template updates across policy to align with Clinical Policy Development template; once-per-lifetime limit moved to Attachment A (09/01/2024).

1Lifetime limit (procedures)

3CDT codes listed

1974Original effective year

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Coverage Summary

This policy covers Surgery of the Lingual Frenulum (frenectomy, frenotomy, frenuloplasty) for treatment of ankyloglossia (tongue-tie) under NC Medicaid (Policy No: 1A-16), originally effective 1974. Coverage stance: covered_with_criteria. The policy applies statewide to NC Medicaid beneficiaries and includes EPSDT provisions for beneficiaries under 21. A once-per-lifetime limit on surgery is noted (1 per lifetime). Prior approval is required for beneficiaries aged 2 years and older, with exemptions for beneficiaries aged 1 year or younger who meet specific criteria.

Key Policy Facts

Original effective year1974

Lifetime limit (procedures)1

CDT codes listed3

Last review2024-09-01

Medical Necessity / Coverage Criteria

Definitions & Background

This policy defines surgical procedures on the lingual frenulum—incision, excision, or surgical alteration—to free the tongue and increase range of motion for treatment of ankyloglossia (tongue-tie).

Clinical context includes feeding difficulties in infants, speech/articulation development concerns in children, and oral hygiene issues (including gingival recession adjacent to lower anterior teeth) that result from restricted tongue mobility.

EPSDT considerations: for beneficiaries under 21 years of age, EPSDT (42 U.S.C. § 1396d(r)) requires coverage of services that are medically necessary to correct or ameliorate a condition identified through screening. EPSDT does not eliminate prior approval requirements; providers must still follow prior approval processes and submit documentation showing EPSDT criteria are met when requesting services for beneficiaries under 21.

Ankyloglossia (Tongue-tied): Condition ranging from malposition of the frenulum to partial or total fusion of the tongue to the floor of the mouth that restricts tongue movement and may cause feeding or speech difficulties.

Frenectomy: A surgical procedure that removes the lingual frenum of the tongue.

Frenotomy: A surgical procedure where the frenum is incised and not removed.

Frenuloplasty: Surgical revision of the lingual frenum, typically with Z-plasty.

Frenulectomy: Excision of a wedge section of the frenum (methods of excising a frenum).

Coding

CPT/Procedure / CDT dental codes referenced for billingmixedCovered

41010	CPT code referenced with CDT mapping to D7961
41115	CPT code referenced with CDT mapping to D7962
41520	CPT code referenced with CDT mapping to D7963
D7961	Current Dental Terminology (CDT) code
D7962	Current Dental Terminology (CDT) code
D7963	Current Dental Terminology (CDT) code

Unlisted Procedure or Service guidanceCPT|HCPCS

No codes listed

Report the most specific ICD-10-CM, CPT, HCPCS, or CDT code that supports medical necessity and use the current edition in effect at time of service.

When no specific CPT or HCPCS code exists for the procedure, report the service using the appropriate unlisted procedure or service code and follow the CPT/HCPCS instructions for Unlisted Procedure and Special Report.

The policy references CPT/Procedure/CDT crosswalks for commonly used codes (examples listed in the policy include CPT 41010 → CDT D7961, 41115 → D7962, 41520 → D7963) and notes that providers shall report the most specific billing code that accurately and completely describes the procedure.

Providers must follow NCTracks, national coding guidelines, and the NC Medicaid Provider Claims and Billing Assistance Guide for claim submission and code specificity.

Place of service can include Inpatient, Outpatient, Physician's Office, or Dental Office; report codes on the appropriate claim form per guidance (Professional CMS-1500/837P or Institutional UB-04 per National Uniform Billing Guidelines).

Provider Actions & Requirements

Prior Authorization

Prior approval requirement

Prior approval is required for Surgery of the Lingual Frenulum. Providers must obtain prior approval before rendering the service for beneficiaries aged 2 years and older. Prior approval is not required for beneficiaries aged 1 year or younger who meet the specific criteria in Section 3.2.1.

41010
41115
41520
D7961
D7962
D7963

Documentation Required

Prior approval submission documentation

Submit the prior approval request and all health care and supporting records that demonstrate the beneficiary meets the specific criteria in Subsection 3.2. For Medicaid beneficiaries under 21 years of age, include documentation showing EPSDT criteria are met and include evidence-based literature supporting the request when available.

Revision History

09/01/2024material_changeLatest

Material change clarifying prior approval age threshold: text 'over 1 year of age' was changed to '2 years of age and older' for prior approval requirements.

09/01/2024non_material_revision

Definitions previously in subsection 5.2.2 were moved to Section 1.0 and updated.

09/01/2024non_material_revision