CurrentDelta Dental of OhioPolicy 282.38.v2

Clinical Criteria Frenectomy and Frenuloplasty

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Clinical criteria for evaluating the medical necessity and clinical appropriateness of frenectomy, frenulectomy, and frenuloplasty when benefit payment requires utilization management review.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria Frenectomy and Frenuloplasty

Policy CodePolicy 282.38.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateNot specified

Key ActionObtain prior authorization for D7960 when billed as a separate procedure not incidental to another procedure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Applicable CDT procedure codes

7Qualifying clinical indications

D7960Procedure requiring prior authorization

≤24 monthsAge threshold for physician evaluation and referral

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CurrentDelta Dental of OhioPolicy 282.38.v2

Clinical Criteria Frenectomy and Frenuloplasty

Customize your policy alerts

Sign up for deltadentalofohio Policy 282.38.v2 alerts

Get alerted when Policy 282.38.v2 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Clinical criteria for evaluating the medical necessity and clinical appropriateness of frenectomy, frenulectomy, and frenuloplasty when benefit payment requires utilization management review.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria Frenectomy and Frenuloplasty

Policy CodePolicy 282.38.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateNot specified

Key ActionObtain prior authorization for D7960 when billed as a separate procedure not incidental to another procedure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Applicable CDT procedure codes

7Qualifying clinical indications

D7960Procedure requiring prior authorization

≤24 monthsAge threshold for physician evaluation and referral

Disapproval-risk conditions

Coverage Criteria

Qualifying clinical indications

Frenectomy or frenuloplasty is medically necessary and clinically appropriate when the dental record documents a qualified health professional’s diagnosis of a dental or medical condition for which the procedure is generally accepted treatment, and at least one of the following indications applies:

At least one qualifying indication

Breastfeeding or suckling impairment: Impairment of infant breastfeeding or suckling, including an incompetent palatal seal or lip closure.
Swallowing or mastication difficulty: Frenulum-related swallowing or masticatory difficulties.
Speech pathology: Frenulum-related speech pathology.
Periodontal damage: A frenulum attachment coronal to the mucogingival junction is causing damage to the periodontium, including gingival recession or stripping.
Orthodontic benefit: The procedure will eliminate or reduce the need for orthodontic treatment or prevent a stable orthodontic outcome from being compromised by adverse positioning of the frenulum attachment.
Restorative or prosthetic interference: The frenulum attachment interferes with dental restorative treatment or with placement or function of a fixed or removable prosthetic appliance.
Oral hygiene interference: The frenulum attachment interferes with required oral hygiene, particularly when developmental or physical conditions limit the individual’s ability to maintain adequate oral health.

Nonstandard conditions

Patients who do not meet the published qualifying criteria may still be considered when relevant clinicians provide documentation explaining why coverage is necessary for a condition not included in the criteria.

Exception review: Documentation from relevant clinicians explains the necessity of frenectomy or frenuloplasty for the condition not included in the published qualifying criteria.

Coverage remains subject to professional review and applicable dental plan provisions.

Additional coverage considerations

The following additional circumstances may be applied in coverage determinations when clinically applicable. They do not constitute automatic approval criteria.

One or more additional considerations

Frequent pain or injury: The frenulum is prone to frequent pain and injury from normal daily dental care activities, such as brushing-induced abrasions or lacerations.
Psychological disorder from cosmetic compromise: A qualified mental health provider has diagnosed a psychological disorder resulting from pronounced cosmetic compromise caused by a frenulum attachment, such as a large anterior diastema.
Program-specific criteria: The member’s dental benefit program establishes criteria defining when frenectomy or frenuloplasty is medically necessary and eligible for coverage or imposes other limitations on coverage.
Program-specific criteria and limitations are applied when evaluating medical necessity.

Not medically necessary or inadvisable situations

Depending on the clinical circumstances, treatment may be considered not medically necessary, inadvisable, or deficient in clinical quality and may result in disapproval following professional review.

Any disapproval condition

Cosmetic purpose: The procedure is provided primarily for cosmetic reasons.
Adjacent-structure risk: The procedure may compromise vital adjacent structures, including nearby neurovascular bundles such as the lingual or mental nerves.
Normal primary-dentition spacing: The procedure is provided to address normal interdental spacing in the primary dentition.
Comorbid disease or local infection: The patient has an acute or chronic comorbid disease state or local infection in which frenectomy or frenuloplasty may create greater risk to health than the perceived benefit.

Frenectomy or frenuloplasty provided primarily for cosmetic reasons is subject to disapproval as not medically necessary or not clinically appropriate.

Frenectomy or frenuloplasty performed to address normal interdental spacing in the primary dentition is subject to disapproval.

Treatment is contraindicated or may be disapproved when the frenulum is near vital adjacent neurovascular or vascular structures and the procedure could cause permanent tissue damage, including damage to nervous or vascular tissues.

Treatment may be determined not medically necessary when an acute or chronic comorbid disease state or local infection creates a greater risk to the patient’s health than the anticipated benefit of frenectomy or frenuloplasty.

For D7960, treatment may be disapproved when a health condition could adversely affect soft-tissue healing, including severe Ehlers-Danlos syndrome or treatment with chemotherapy agents.

Procedure Codes and Coding Requirements

Applicable Dental Procedure Codesmixed

D7961	buccal / labial frenectomy (frenulectomy)
D7962	lingual frenectomy (frenulectomy)
D7963	frenuloplasty

Appendix A Procedure Codemixed

D7960

Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure

Age for physician evaluation and referral

RequirementPhysician evaluation and referral is required for all patients 24 months of age and younger.

Applicable procedureD7960 frenulectomy, also known as frenectomy or frenotomy.

Breastfeeding or suckling difficultyWhen a physician diagnoses the frenum attachment as the primary cause of infant breastfeeding, suckling, or latching difficulty, medical necessity will be considered.

Preoperative periodontal charting recency

TimingPreoperative six-point periodontal pocket-depth charting must be performed within 12 months of treatment, when applicable.

Required findings

Provider Submission and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for D7960 when billed as a separate procedure not incidental to another procedure. For patients 24 months of age or younger, submit the required physician evaluation and referral; medical-necessity consideration applies when a physician diagnoses the frenum attachment as the primary cause of breastfeeding, suckling, or latching difficulty.

D7960: Frenulectomy, also known as frenectomy or frenotomy, separate procedure not incidental to another procedure.
Patients 24 months of age or younger require physician evaluation and referral.

Documentation Required

Document the Diagnostic Rationale

Submit documentation consistent with the patient record explaining the diagnostic rationale for frenectomy or frenuloplasty, including the condition or diagnosis requiring treatment and supporting dental and medical history.

Clinical Background

Oral frenulums are mucosal tissue folds containing muscle and connective tissue that attach the lip, cheek, or tongue to oral mucosa, gingiva, alveolar tissues, or the floor of the mouth. An adversely positioned frenulum can affect breastfeeding or nourishment, swallowing, speech, periodontal health, tooth eruption and positioning, orthodontic stability, oral hygiene, restorative treatment, or prosthetic appliance function.

Definitions

Frenectomy / frenulectomy

DefinitionComplete removal of an oral frenulum, including any underlying bone attachment.

Also known asFrenulectomy is also referred to as frenectomy or frenotomy.

TechniquesThe procedure may be performed using conventional scalpel technique, electrosurgery, or laser surgery.

Frenuloplasty

DefinitionFrenulum excision accompanied by excision or repositioning of aberrant muscle and Z-plasty or another local flap closure.

Muscle treatmentThe procedure includes excision or repositioning of aberrant muscle.

Closure

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria Frenectomy and Frenuloplasty

Policy CodePolicy 282.38.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateNot specified

Key ActionObtain prior authorization for D7960 when billed as a separate procedure not incidental to another procedure.

SourceLink

On This Page

D7960 healing-risk condition: For D7960, a health condition is present that could adversely affect soft-tissue healing, including severe Ehlers-Danlos syndrome or treatment with chemotherapy agents.

This is an Appendix A contraindication for D7960.

The charting includes clinical attachment loss, tooth mobility, bleeding on probing, and furcation involvement.

Documentation contextThe charting is submitted as part of the dental record supporting medical necessity or clinical appropriateness review.

Include the clinical reason treatment is needed and the relevant patient history.

Coverage may be evaluated under applicable dental benefit program criteria.

Documentation Required

Include Referring Professional Records

Include applicable treatment records from referring or involved dental, medical, or mental health professionals, including records documenting relevant diagnoses or a qualified mental health provider's diagnosis when applicable.

Submit dental, medical, or mental health records when they support the diagnosis or treatment need.
For patients 24 months of age or younger, include the required physician evaluation and referral.

Documentation Required

Submit Diagnostic Radiographs

Submit recent diagnostic radiographs of the involved dento-alveolar complex when applicable to the diagnosis and treatment plan.

Radiographs may be relevant to demonstrating resultant bone loss or other clinically significant findings.

Documentation Required

Provide Periodontal Charting

When applicable, submit preoperative six-point periodontal pocket-depth charting performed within 12 months of treatment.

Include clinical attachment loss, tooth mobility, bleeding on probing, and furcation involvement.

Documentation Required

Submit Diagnostic Photographs

Submit photographs that clearly demonstrate the affected areas and support the requested treatment.

Ensure the areas relevant to the frenectomy or frenuloplasty are clearly visible.

Denial Risk

Flag Cosmetic, Spacing, or Neurovascular Risk

Identify circumstances that may support disapproval, including treatment provided primarily for cosmetic reasons, treatment to address normal interdental spacing in the primary dentition, or treatment that may compromise nearby neurovascular structures.

Cosmetic treatment alone may not support coverage.
Frenectomy or frenuloplasty for normal spacing in the primary dentition may be disapproved.
Assess proximity to vital adjacent structures, including the lingual or mental nerves.

Denial Risk

Report Comorbidity or Local Infection

Disclose any acute or chronic comorbid disease state or local infection that could make frenectomy or frenuloplasty pose a greater health or healing risk than the anticipated benefit.

Identify conditions that may affect soft-tissue healing, including severe Ehlers-Danlos syndrome or use of chemotherapy agents.
Report local infection or other comorbid conditions that increase procedural risk.

Denial Risk

Insufficient Documentation May Cause Disapproval

If the practitioner cannot provide applicable clinical and radiographic information, benefit payment may be disapproved. Delta Dental of Ohio may also request additional clinical information relevant to the patient's care.

Submit all documentation applicable to the patient's diagnosis, medical necessity, and clinical appropriateness.
Ensure the submission supports the treatment plan and requested procedure.

Denial Risk

D7960 Contraindications

D7960 may be denied when the frenum attachment is in close proximity to vascular or nervous structures and the incision and drainage process creates a risk of permanent damage to nervous or vascular tissues.

Evaluate the relationship of the attachment to nearby vasculature and nervous structures before treatment.
Approval may also be contraindicated when health conditions could affect soft-tissue healing.

Closure may use Z-plasty or another local flap technique.

Oral frenulum

DefinitionThin folds of intraoral mucosal tissue containing muscle and connective tissue fibers.

Lip or cheek attachmentThe tissue folds attach the lip or cheek to alveolar mucosa, gingiva, or underlying periosteum.

Lingual attachmentThe lingual frenulum extends from the underside of the tongue to the floor of the mouth.

TypesOral frenulums include the maxillary labial, mandibular labial, and lingual frenulums.