Number: 011
(Updated)

Subject: Frenulectomy (frenectomy, frenotomy) or frenuloplasty

Date: March 15, 2017

Important note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:

• Clinical outcome studies in the peer-reviewed published medical and dental literature
• Regulatory status of the technology
• Evidence-based guidelines of public health and health research agencies
• Evidence-based guidelines and positions of leading national health professional organizations
• Views of physicians and dentists practicing in relevant clinical areas
• Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information. 

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Visit the CMS's Coverage Database

Policy

Aetna considers this surgical procedure to be dental-in-nature (DIN) oral surgery. Coverage may be available for DIN oral surgical procedures under either medical or dental plans.

Background

The frenum is a restraining structure consisting of connective tissue covered by a mucous membrane that attaches the cheek, lips and/or tongue to the associated dental mucosa. The frenum may be excised when the tongue has limited mobility and is diagnosed as ankyloglossia (tongue-tied); when the frenum is contributing to a large diastema (space) between teeth; when the frenum is interfering with a prosthetic appliance; or when it is contributing to the etiology of periodontal disease and/or to recession of the gingival tissue.¹

Methods of excising a frenum include frenulectomy (frenectomy, frenotomy) and frenuloplasty. According to the CDT 2016 descriptors for frenuloplasty, it is "an excision of frenum with accompanying excision or repositioning of aberrant muscle and Z-plasty or other local flap closure."¹ The frenulectomy procedure involves a simple excision or removal of a wedge section of the frenum. 

Based on the CDT 2016 nomenclature, a frenulectomy (frenectomy or frenotomy) is a "separate procedure" (not incidental to another surgical procedure such as a free soft tissue graft, subepithelial connective tissue graft or soft tissue allograft).¹ The descriptors for free soft tissue graft procedure, subepithelial connective tissue graft procedure and soft tissue allograft procedures indicate that these procedures may be used to eliminate the pull of frena and muscle attachments² and as such, frenectomy/frenulectomy/frenotomy /frenuloplasty would be considered incidental to the soft tissue graft procedure. 

A common type of frenectomy is a lingual frenectomy. This procedure is performed on patients who have been diagnosed with ankyloglossia. In these individuals, the frenum attachment of the tongue is attached to the lower jaw in such a position that it prevents unrestricted movement of the tongue and typically affects speech. The procedure involves inferior repositioning of the attachment of the lingual frenum to enhance protrusive and lateral movement of the tongue and subsequent improvement of speech and deglutition.

Codes

CDT¹:
D7960 -- Frenulectomy – (frenectomy or frenotomy) – separate procedure not incidental to another procedure 
D7963 -- Frenuloplasty - Excision of frenum with accompanying excision or repositioning of aberrant muscle and z-plasty or other local flap closure

CPT³:
40806 -- Incision of labial frenum (frenotomy)
40819 -- Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)
41010 -- Incision of lingual frenum (frenotomy)
41115 -- Excision of lingual frenum (frenectomy)
41520 -- Frenoplasty (surgical revision of frenum, for example, with Z-plasty)

Refer to Medical Clinical Policy Bulletin #116 -- Frenulectomy for Ankyloglossia

Revision Dates

Original: November 22, 2005
Updated: November 28, 2007, December 29, 2008; December 21, 2009; February 28, 2011; April 9, 2012; April 30, 2013; April 17, 2014; March 7, 2016; March 15, 2017
Revised: November 20, 2006

The above policy is based on the following references:

¹American Dental Association. Current dental terminology, CDT 2017.*

²American Medical Association. Current procedural terminology, CPT 2010; 151-152.**

³Proceedings of the 1996 World Workshop in Periodontics. Lansdowne, VA, July 13-17, 1996. Ann Periodontol. 1996 Nov;1(1): 676, 704.

⁴Kruger, Gustav O. Textbook of Oral Surgery. St. Louis: C.V. Mosby Company; 1974.

*Copyright 2016 American Dental Association. All rights reserved. 
**Copyright 2010 American Medical Association. All rights reserved.

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.