Number: 011
(Updated)

Subject: Frenulectomy (frenectomy, frenotomy) or frenuloplasty

Date: May 6, 2020

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

According to the CDT 2019 Dental Procedure Codes book the definition of frenulectomy (frenectomy or frenotomy) is the removal or release of mucosal and muscle elements of a buccal, labial or lingual frenum that is associated with a pathological condition or interferes with proper oral development or treatment.¹

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. The frenulectomy procedure involves a simple excision or removal of a wedge section of the frenum. 

Based on the CDT 2019 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 attachments.¹

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.

Frenulectomy (Frenectomy, Frenotomy) may be considered incidental to a soft tissue graft procedure. When a frenulectomy is done at the same time/same surgery as soft tissue grafting, the frenulectomy is considered inclusive to soft tissue grafting. When performed separately, it is considered a separate procedure.

Codes

CDT¹:
D4277 - Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft                                                                        D4273 - autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position in graft                                                      D4275 - non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft                                                                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; April 26, 2018; May 6, 2020
Revised: November 20, 2006

The above policy is based on the following references:

¹American Dental Association. CDT 2020 Dental Procedure Codes.*

²Proceedings of the 1996 World Workshop in Periodontics. Lansdowne, VA, July 13-17, 1996. Ann Periodontol. 1996 Nov;1(1): 676, 704.

³Kruger, Gustav O. Textbook of Oral Surgery. St. Louis: C.V. Mosby Company; 1974.

*Copyright 2019 American Dental 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.