CommercialCoverageMedium impact
Frenectomy or Frenotomy for Ankyloglossia (CPB 0116, reviewed 2026-03-26)
Aetna·Pediatrics, ENT (Ear, Nose & Throat), Oral & Maxillofacial Surgery +2 more·Medical Policy
Effective date
Mar 26, 2026
We identified it
Aug 16, 2026
Summary
Aetna's updated policy (CPB 0116, effective 2026-03-26) clarifies coverage for frenectomy/frenotomy procedures for ankyloglossia. Medical necessity is limited to cases with newborn feeding difficulties or childhood articulation problems. Multiple treatments are now classified as experimental/unproven, including atmospheric plasma procedures, lingual frenuloplasty for non-feeding/speech indications, oro-myofunctional therapy, and prophylactic procedures. Billing teams must update denial logic and prior authorization criteria to align with these restrictions.
Action Required
Before 2026-03-26: Billing team must update claim adjudication rules and prior authorization protocols in billing system to reflect new experimental/unproven restrictions. Specifically: (1) CPT 41115 claims using atmospheric plasma method must be denied; (2) CPT 41520 (lingual frenuloplasty) claims for dental clenching, mouth breathing, myofascial tension, or snoring (ICD-10 F45.8, G47.63, M79.18, R06.5, R06.83) must be denied as experimental; (3) Claims for oro-myofunctional therapy without corresponding frenectomy must be denied; (4) Prophylactic frenectomy/frenotomy/frenuloplasty claims (without P92.01-P92.9 or Q38.1 diagnoses indicating feeding/articulation problems) must be denied. Update prior authorization templates to require documentation of feeding difficulties or articulation problems for CPT 40806, 40819, 41010, 41115, 41520 and HCPCS D7960, D7961, D7962. Train billing and clinical staff on new restrictions. Update denial letters to reference experimental classification for denied claims.