Mountain State Medical Policy Bulletin |
Section: | Surgery |
Number: | S-81 |
Topic: | Congenital Cleft Palate Repair |
Effective Date: | August 1, 2005 |
Issued Date: | January 30, 2006 |
Date Last Reviewed: | 01/2006 |
Indications and Limitations of Coverage
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:
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.
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. |
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42299 |
®Under the Federal Employee Program, orthodontic treatment for congenital cleft palate (procedure code 42299) is not eligible. |
PRN References 06/1996, Cleft lip and palate repair, codes and reimbursement for |
[Version 001 of S-81] |