CG-SURG-122 Lingual Frenotomy for Ankyloglossia-Related Feeding Difficulties

This policy addresses lingual frenotomy for infants with ankyloglossia-related feeding difficulties. It is medically necessary only when all criteria are met: documented feeding impairment (e.g., poor latch or maternal nipple pain), severity confirmed by a validated tool with a TABBY or BTAT score ≤5, and failure of conservative management; it is not covered when these criteria are not met or for prophylactic/non–feeding indications. Coverage is limited to infant feeding dysfunction with validated severity scoring.

"A lingual frenotomy is consideredmedically necessaryfor the treatment of ankyloglossia-related feeding difficulties whenallthe following criteria (1-4) are met:"

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