Clinical Policy Bulletin: Frenectomy or Frenotomy for Ankyloglossia
Aetna considers inferior lingual frenectomy or lingual frenotomy for ankyloglossia medically necessary when newborn feeding difficulties or childhood articulation problems exist.
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”.
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.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
CPT codes not covered for indications listed in the CPB:
HCPCS code not covered for indications listed in the CPB:
Frenulectomy (frenectomy or frenotomy) - separate procedure
ICD-9 code covered if selection criteria are met:
Other ICD-9 codes related to the CPB:
Feeding problems in newborn
Other developmental speech or language disorder
The above policy is based on the following references:
Schuller DE, Schleuning II AJ. DeWeese and Saunders' Otolaryngology-Head and Neck Surgery. 8th ed. St. Louis, MO: Mosby; 1994:216-217.
Welch KJ, Randolph JG, Ravitch MM, et al., eds. Pediatric Surgery. 4th ed. Chicago, IL: Year Book Medical Publishers, Inc; 1986:511.
Marmet C, Shell E, Marmet R. Neonatal frenotomy may be necessary to correct breast feeding problems. J Hum Lact. 1990;6(3):117-121.
Messner AH, Lalakea ML, Aby J, et al. Ankyloglossia: Incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg. 2000;126(1):36-39.
Masaitis NS, Kaempf JW. Developing a frenotomy policy at one medical center: A case study approach. J Hum Lact. 1996;12(3):229-232.
Lalakea ML, Messner AH. Ankyloglossia: Does it matter? Pediatr Clin North Am. 2003;50(2):381-397.
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.
Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: Clinical suggestions for diagnosis and management. Pediatr Dent. 2005;27(1):40-46.
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.
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.
Segal LM, Stephenson R, Dawes M, Feldman P. Prevalence, diagnosis, and treatment of ankyloglossia: Methodologic review. Can Fam Physician. 2007;53(6):1027-1033.
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.
American Academy of Pediatric Dentistry (AAPD). Guideline on pediatric oral surgery. Chicago, IL: American Academy of Pediatric Dentistry (AAPD); 2010.
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.
Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics. 2011;128(2):280-288.
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