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Frenectomy or Frenotomy for Ankyloglossia

Number: 0116

Policy

Aetna considers inferior lingual frenectomy or lingual frenotomy for ankyloglossia medically necessary when newborn feeding difficulties or childhood articulation problems exist.

Background

Ankyloglossia, or tongue-tie, exists when the inferior lingual frenulum attaches to the bottom of the tongue and restricts its movement.  This condition can impair the normal mobility of the tongue and interfere with speech or newborn feeding.

If the tongue can touch the anterior dentition, mobility is adequate for the development of normal speech.  However, in situations where the inferior lingual frenulum significantly impedes tongue excursion, a frenulectomy may be performed in order to free the tongue.

An assessment by the National Institute for Health and Clinical Excellence (NICE, 2005) concluded that “[c]urrent 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”.

A position statement by the Canadian Paediatric Society (Rowan-Legg, et al., 2011) found: "Associations between tongue-tie and breastfeeding problems in infants have been inconsistent, and are a longstanding source of controversy in the medical community. Definitions of ankyloglossia vary, and management suggestions are not based on randomized controlled trials. ... Based on current available evidence, frenotomy cannot be recommended. If, however, the association between significant tongue-tie and major breastfeeding problems is clearly identified and surgical intervention is deemed necessary, frenotomy should be performed by a clinician experienced with the procedure and with appropriate analgesia."

Aras and colleagues (2010) 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.  A total of 16 referred patients with tongue mobility complaints were included in this study.  A GaAlAs laser device with a continuous wavelength of 808 nm was used in the diode group.  Frenulums were incised by applying 2 W of laser power.  The Er:YAG laser device with a continuous wavelength of 2,940 nm was used in the Er:YAG group.  Frenulums were incised by applying 1 W of laser power.  The acceptability of the lingual frenectomy without local anesthesia and the degree of the post-surgical discomfort were evaluated.  Although the majority of patients (n = 6) could be operated on without local anesthesia in the Er:YAG group, all patients could not be operated on without local anesthetic agent in the diode group.  There were no differences between the 2 groups with regard to pain, chewing, and speaking on the 1st or 7th day after surgery, whereas patients had more pain in the Er:YAG group than in the diode group the first 3 hrs after surgery.  The authors concluded that these findings indicate that only the Er:YAG laser can be used for lingual frenectomy without local anesthesia, and there was no difference between the 2 groups regarding the degree of the post-surgical discomfort except in the first 3 hrs.  Thus, these results indicate that the Er:YAG laser is more advantageous than the diode laser in minor soft-tissue surgery because it can be performed without local anesthesia and with only topical anesthesia.

Buryk et al (2011) noted that ankyloglossia has been associated with a variety of infant-feeding problem and that frenotomy commonly is performed for relief of ankyloglossia.  The investigators conducted a randomized, single-blinded, controlled trial to determine whether frenotomy for infants with ankyloglossia improved maternal nipple pain and ability to breastfeed. A secondary objective was to determine whether frenotomy improved the length of breastfeeding. Over a 12-month period, neonates who had difficulty breastfeeding and significant ankyloglossia were assigned to either a frenotomy (30 infants) or a sham procedure (28 infants) and breastfeeding was assessed by a preintervention and postintervention nipple-pain scale and the Infant Breastfeeding Assessment Tool. Study subjects were followed two weeks post=procedure and at regularly scheduled follow-ups over a 1-year period. The infants in the sham group were given a frenotomy before or at the 2-week follow-up if it was desired. Both groups demonstrated statistically significantly decreased pain scores after the intervention, but the frenotomy group improved significantly more than the sham group (P < .001). Breastfeeding scores significantly improved in the frenotomy group (P = .029) without a significant change in the control group. All but 1 parent in the sham group elected to have the procedure performed when their infant reached 2 weeks of age, which prevented additional comparisons between the 2 groups. The investigators demonstrated immediate 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 signficant ankyloglossia.

Steehler and colleagues (2012) measured maternal breast feeding benefit after infant frenotomy.  In addition, these researchers examined if timing of neonatal/infant frenotomy affects outcome.  Medical records of neonates and infants suspected to have ankyloglossia between April 2006 and February 2011 were reviewed.  Patient demographic data were compiled.  A telephone survey was conducted to gather data on this cohort of patients.  Neonatal and infant consultations (n = 367) were performed for feeding difficulties due to suspected ankyloglossia, 302 of these infants underwent frenotomy for ankyloglossia.  A total of 91 mothers agreed to participate in a follow-up telephone survey regarding the intervention.  Results showed that 80.4 % of mothers strongly believed the procedure benefited their child's ability to breast-feed, and 82.9 % of mothers were able to initiate/resume breast-feeding after the procedure was performed.  The belief that frenotomy significantly benefitted an infant's ability to feed significantly differed in patients that had the procedure performed in the first week of life (86 %) as compared to infants that had the procedure performed after the first week of life (74 %) (p < 0.003).  The authors concluded that based on maternal observations, when frenotomy is performed on neonates with ankyloglossia and feeding difficulties in the first week of life, there is more benefit than when it is performed after the first week of life.  The population of patients with ankyloglossia is predominantly male with a high familial/genetic correlation associated with the phenotypic trait.  They stated that frenotomy for ankyloglossia demonstrated a high degree of maternal satisfaction; is well-tolerated and has been shown to improve breast-feeding and decrease pain and difficulty associated with breast-feeding.

O'Callahan et al (2013) evaluated the effect of office-based frenotomy on reversing breast-feeding difficulties among infants with problematic ankyloglossia, and examined characteristics associated with anterior and posterior ankyloglossia.  Mothers of infants who underwent a frenotomy for ankyloglossia from December 2006 through March 2011 completed a post-intervention web-based survey about breast-feeding difficulties they experienced before and after the frenotomy.  Maternal-infant dyads had been referred from health providers to a primary care practice for assessment of ankyloglossia.  Infants were subsequently classified as having no ankyloglossia, anterior (Type I or Type II) or posterior (Type III or Type IV).  There were 311 infants evaluated for ankyloglossia and 299 (95 %) underwent a frenotomy.  Most infants were classified as having Type III (36 %) or IV (49 %) ankyloglossia compared to only 16 % with anterior (Type I and Type II combined).  Differences by classification type were found for gender (p = 0.016), age (p = 0.017), and maxillary tie (p = 0.005).  Among survey respondents (n = 157), infant latching significantly improved (p < 0.001) from pre- to post-intervention for infants with posterior ankyloglossia.  Both the presence and severity of nipple pain decreased from pre- to post-intervention among all classifications (p < 0.001).  Additionally, 92 % of respondents breast-fed exclusively post-intervention.  The mean breast-feeding duration of 14 months did not differ significantly by classification.  The authors concluded that breast-feeding difficulties associated with ankyloglossia in infants, particularly posterior, can be improved with a simple office-based procedure in most cases.  

Toner et al (2014) determined parental satisfaction and cost-effectiveness of having a frenotomy performed in the office setting versus in the operating room under general anesthesia.  After obtaining IRB approval at The Children's Hospital of Philadelphia (CHOP), these investigators performed a retrospective chart review of patients having a frenotomy in the office between 2003 and 2008.  A total of 55 patients met the criteria and 25 were consented and their parents interviewed.  All participants reported an improvement in feeding within 1 day and up to 2 weeks following the procedure.  Parents also reported being somewhat satisfied to very satisfied with having the frenotomy performed in the office versus under general anesthesia.  There were no complications reported.  Performing the frenotomy in the office provided patients with satisfaction as well as cost savings.  The surgical fee for a frenotomy in the office was $850 and was the same as if the procedure was performed in the operating room.  Performing a frenotomy under general anesthesia included extra cost that consisted of an anesthesia fee of $500 to $900 and hospital charges ranging from $500 to $8,000.  The authors concluded that performing the frenotomy in the office on their 25 patients resulted in a cost savings of more than $240,000 and the avoidance of general anesthesia in the first few weeks of life.  They stated that office frenotomy should be considered in children with ankyloglossia who present with difficulty nursing in the first week of life.

CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
41010 Incision of lingual frenum (frenotomy)
41115 Excision of lingual frenum (frenectomy)
CPT codes not covered for indications listed in the CPB:
40806 Incision of labial frenum (frenotomy)
40819 Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)
41520 Frenoplasty (surgical revision of frenum, e.g., with Z-plasty)
HCPCS code not covered for indications listed in the CPB:
D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure
ICD-9 code covered if selection criteria are met:
750.0 Tongue tie
Other ICD-9 codes related to the CPB:
315.39 Other developmental speech or language disorder
779.31 Feeding problems in newborn


The above policy is based on the following references:
    1. Schuller DE, Schleuning II AJ. DeWeese and Saunders' Otolaryngology-Head and Neck Surgery. 8th ed. St. Louis, MO: Mosby; 1994:216-217.
    2. Welch KJ, Randolph JG, Ravitch MM, et al., eds. Pediatric Surgery. 4th ed. Chicago, IL: Year Book Medical Publishers, Inc; 1986:511.
    3. Marmet C, Shell E, Marmet R. Neonatal frenotomy may be necessary to correct breast feeding problems. J Hum Lact. 1990;6(3):117-121.
    4. Messner AH, Lalakea ML, Aby J, et al. Ankyloglossia: Incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg. 2000;126(1):36-39.
    5. Masaitis NS, Kaempf JW. Developing a frenotomy policy at one medical center: A case study approach. J Hum Lact. 1996;12(3):229-232.
    6. Wright JE. Tongue-tie. J Paediatr Child Health. 1995;31(4):276-278.
    7. Messner AH, Lalakea ML. Ankyloglossia: Controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54(2-3):123-131.
    8. Kotlow LA. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Quintessence Int. 1999;30(4):259-262.
    9. Newkirk GR. Tongue-tie snipping (frenotomy) for ankyloglossia. In: Procedures for Primary Care Physicians. 1st ed. JL Pfenninger, ed,. St Louis, MO: Mosby-Year Book Inc; 1994:287-290.
    10. Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg. 2002;127(6):539-545.
    11. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: Assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63.
    12. Community Paediatrics Committee. Ankyloglossia and breastfeeding. Canadian Paediatric Society Position Statement. Paediatr Child Health. 2002;7(4):269-270. Available at: http://www.cps.ca/english/statements/CP/cp02-02.htm. Accessed April 18, 2003.
    13. Lalakea ML, Messner AH. Ankyloglossia: Does it matter? Pediatr Clin North Am. 2003;50(2):381-397.
    14. Dolberg S, Botzer E, Grunis E, Mimouni F. A randomized, prospective, blinded clinical trial with cross-over of frenotomy in ankyloglossia: Effect on breast-feeding difficulties. Pediatr Res. 2002;52(5):822-827.
    15. Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: Clinical suggestions for diagnosis and management. Pediatr Dent. 2005;27(1):40-46.
    16. National Institute for Health and Clinical Excellence (NICE). Division of ankyloglossia (tongue-tie) for breast feeding. Interventional Procedure Guidance 149. London, UK: NICE; December 2005. Available at: http://www.nice.org.uk/page.aspx?o=284322. Accessed February 15, 2006.
    17. Dollberg S, Botzer E, Grunis E, Mimouni FB. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: A randomized, prospective study. J Pediatr Surg. 2006;41(9):1598-1600.
    18. Segal LM, Stephenson R, Dawes M, Feldman P. Prevalence, diagnosis, and treatment of ankyloglossia: Methodologic review. Can Fam Physician. 2007;53(6):1027-1033.
    19. Aras MH, Göregen M, Güngörmüş M, Akgül HM. Comparison of diode laser and Er:YAG lasers in the treatment of ankyloglossia. Photomed Laser Surg. 2010;28(2):173-177.
    20. American Academy of Pediatric Dentistry (AAPD). Guideline on pediatric oral surgery. Chicago, IL: American Academy of Pediatric Dentistry (AAPD); 2010.
    21. Pie-Sanchez J, Espana-Tost AJ, Arnabat-Domínguez J, Gay-Escoda C. Comparative study of upper lip frenectomy with the CO2 laser versus the Er, Cr:YSGG laser. Med Oral Patol Oral Cir Bucal. 2012;17(2):e228-e232.
    22. Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics. 2011;128(2):280-288.
    23. Rowan-Legg A; Community Paediatrics Committee, Canadian Paediatrics Society. Ankyloglossia and breastfeeding. Position Statement. Ottawa, ON: Canadian Paediatric Society; April 1, 2011 (reaffirmed February 1, 2014).
    24. Olivi G, Signore A, Olivi M, Genovese MD. Lingual frenectomy: Functional evaluation and new therapeutical approach. Eur J Paediatr Dent. 2012;13(2):101-106.
    25. Steehler MW, Steehler MK, Harley EH. A retrospective review of frenotomy in neonates and infants with feeding difficulties. Int J Pediatr Otorhinolaryngol. 2012;76(9):1236-1240.
    26. O'Callahan C, Macary S, Clemente S. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol. 2013;77(5):827-832.
    27. Reddy NR, Marudhappan Y, Devi R, Narang S. Clipping the (tongue) tie. J Indian Soc Periodontol. 2014;18(3):395-398.
    28. Ito Y. Does frenotomy improve breast-feeding difficulties in infants with ankyloglossia? Pediatr Int. 2014;56(4):497-505.
    29. Toner D, Giordano T, Handler SD. Office frenotomy for neonates: Resolving dysphagia, parental satisfaction and cost-effectiveness. ORL Head Neck Nurs. 2014;32(2):6-7.


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