Congenital Cleft Lip Repair Involving the Alveolus

Pre-surgical orthopedic appliance therapy (procedure code 42299) is an eligible procedure for patients with maxillary unilateral or bilateral congenital cleft lips involving bony displacement of the alveolar segments. It does not involve palate deformity.

Payment for 42299 includes the initial insertion of the plastic shell appliance and any associated services (i.e., models, subsequent adjustments). This pre-surgical orthopedic appliance therapy is considered an alternative to lip adhesion surgery (codes 40700-40761).

Orthodontic Treatment for Congenital Cleft Palate Repair

Orthodontic treatment (procedure code 42299) for congenital cleft palates is eligible for patients when all of the following criteria are met:

• Orthodontic treatment involves the maxillary arch;
• Treatment is provided in conjunction with maxillary alveolar bone graft surgery, referred to as pre and post surgical orthodontics;
• The congenital cleft is a complete cleft of the maxillary alveolus.

Payment for code 42299 includes the allowance for both pre-surgical orthodontics to align the alveolar segments of the maxillary arch prior to bone graft surgery, and orthodontic stabilization following bone graft surgery to hold the maxillary alveolar segments in position until the bone grafts have stabilized. When the maxillary segments have stabilized (approximately up to one year following surgery), no payment will be made for additional orthodontics. Individual consideration will be given in rare cases when the bone graft fails and needs to be performed again.

NOTE:

Coverage is limited to the conditions stated above. It does not include coverage for general orthodontics to correct dental malocclusions or for congenital cleft palate patients who do not need alveolar bone graft surgery. Each case and the necessary documentation must be reviewed by a Medical/Dental Director, Physician Advisor, or Professional Consultant prior to payment to verify that the eligibility criteria have been met.

Description

Congenital Cleft Lip Repair Involving the Alveolus

This interceptive orthopedic treatment involves a plastic shell appliance that helps shape the gum and alveolus in a child, typically from birth to age 12 months, when the cleft is particularly wide and goes through the lip and the alveolus. This appliance narrows the cleft lip and assists in the primary repair of that cleft.

Orthodontic Treatment for Congenital Cleft Palate Repair

This comprehensive orthodontic treatment is usually appropriate for patients ranging from ages four to ten years and consists of two phases: pre-surgical orthodontics to align the alveolar segments of the maxillary arch prior to bone graft surgery; and orthodontic stabilization following bone graft surgery to hold the maxillary alveolar segments in position until the bone grafts have stabilized.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program, orthodontic treatment for congenital cleft palate (procedure code 42299) is not eligible.