F3448
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- A lingual frenotomy is consideredmedically necessaryfor the treatment of ankyloglossia-related feeding difficulties whenallthe following criteria (1-4) are met:
- Infant is experiencing feeding difficulties (for example, poor latch, lactating parent nipple pain);and
- Severity of ankyloglossia confirmed by either of the following:Score of 5 or below on the Tongue-tie and Breastfed Babies (TABBY) assessment tool;orScore of 5 or below on the Bristol Tongue Assessment Tool (BTAT);and
- Score of 5 or below on the Tongue-tie and Breastfed Babies (TABBY) assessment tool;or
- Score of 5 or below on the Bristol Tongue Assessment Tool (BTAT);and
- Feeding difficulty persists despite conservative management approaches, which may include the following:Lactation consultation;orSpeech-language pathology consultation;and
1 Active Policy
ANTHEM-CG-SURG-122 — CG-SURG-122 Lingual Frenotomy for Ankyloglossia-Related Feeding Difficulties
Related Codes
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