cleft lip and cleft palate surgical repair by ibe68982


									Medical Necessity Guidelines
Cleft Lip and Cleft Palate Surgical Repair

   Document ID#:                 1035155
   Subject:                      Cleft Lip and Cleft Palate Surgical Repair
   Effective Date:               April 1, 2010

        Clinical Documentation and Prior
        Authorization Required
                                                √       Type of Review - Case Management

        Not Covered                                     Type of Review – Precertification Department
                                                        Administrative Process (Internal Use Only)           MD

    Note: Background, product, and disclaimer information is located at the end of this document.

    A cleft lip, sometimes called "harelip" is a congenital deformity of the upper lip. A cleft palate is an
    opening in the roof of the mouth in which two sides of the palate did not join together. Cleft lips and
    palates can be unilateral or bilateral. The lip, nose and palate structures do not fuse correctly prior to birth
    as noted by a separation of the two sides of the lip. Often the deformity extends to the roof of the mouth
    (palate) and sometimes includes the bone of the upper jaw, which can result in problems with
    development of normal speech. The repair is often completed in stages as described below:
    •     Primary Surgery: Surgery that is undertaken to;
          −   repair the cleft lip deformity
          −   repair the cleft palate
          −   to place a bone graft in the alveolar (gum) cleft.
    •     Secondary Surgery:
          −   Additional or secondary operations to correct residual deformities of the lip or nose.
    Coverage Guidelines
    •     For Members under the age of 19: Tufts Health Plan does not require prior authorization and review
          for primary and secondary cleft lip and cleft palate repair. Fabrication and placement of an oral
          appliance in infants and a differential palatal expansion appliance in young children (to move boney
          facial and or palatal segments in preparation for cleft lip and palate surgery) are covered by Tufts
          Health Plan.
    •     For Members 19 years of age or older: Tufts Health Plan may authorize coverage for cleft lip,
          palate and naso-labial repair for Members 19 years of age or older. Review and prior authorization,
          by a Tufts Health Plan Medical Director, is required.
    •     For Members 19 years of age and older: THP will not cover procedures that are solely for cosmetic
          purposes, to improve the Member’s appearance.
    •     Any associated orthodontia to reposition teeth is considered a dental service and is not covered by
          Tufts Health Plan.

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The following CPT codes require prior authorization for Members 19 years old or older:
    Code         Description
                 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including
                 columellar lengthening; tip only
                 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including
                 columellar lengthening; tip, septum, osteotomies
    40700        Plastic repair of cleft lip/nasal deformity; primary bilateral, one stage procedure
    40701        Plastic repair of cleft lip/nasal deformity; primary bilateral, one of two stages
    40702        Plastic repair of cleft/lip nasal deformity; secondary, by recreation of defect and reclosure
    42200        Palatoplasty for cleft palate, soft and/or hard palate only
    42205        Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only
                 Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar
                 ridge (includes obtaining graft)
    42215        Palatoplasty for cleft palate; major revision
    42220        Palatoplasty for cleft palate; secondary lengthening procedure
    42225        Palatoplasty for cleft palate; attachment pharyngeal flap

1. American Cleft Palate-Craniofacial Association (ACPA). Russell, Barbara M.
   R.N., M.H.P., New England Medical Center, Boston, MA. To the parents of an infant born with a cleft
   of the lip and/or palate: guidelines for care.
2. Lewis, Michael B., M.D., Department of Plastic Surgery, New England Medical Center. Boston, MA.
   Secondary surgery in children with cleft lip and palate.

Approval History
Reviewed by the Clinical Coverage Criteria Committee on November 1998.

Subsequent Endorsement Date(s) and Changes Made:
•     October 2000: Renewed, no changes made
•     October 2001: Renewed, no changes made
•     May 2002: Prior authorization for Members under the age of 19, no longer required
•     July 15, 2003: Renewed, updated to new format. Definitions and descriptions clarified
•     August 20, 2004: Reviewed and renewed without changes
•     October 21, 2005: Reviewed and renewed without changes
•     November 17, 2006: Reviewed and renewed without changes
•     May 7, 2007: Coverage of oral appliance and differential palatal expansion appliance explained,
      limitation regarding the coverage of orthodontia added
•     April 25, 2008: Reviewed, CPT Codes 42180 and 42182 removed from guideline

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•   May 4, 2009: Reviewed and renewed without changes
•   April 2010: Reviewed at MSPAC, no changes.

Background, Product and Disclaimer Information

Medical Necessity Guidelines are developed to determine coverage for Tufts Health Plan benefits, and
are published to provide a better understanding of the basis upon which coverage decisions are made.
Tufts Health Plan makes coverage decisions using these guidelines, along with the Member’s benefit
document, and in coordination with the Member’s physician(s) on a case-by-case basis considering the
individual Member's health care needs.

Medical Necessity Guidelines are developed for selected therapeutic or diagnostic services found to be
safe, but proven effective in a limited, defined population of patients or clinical circumstances. They
include concise clinical coverage criteria based on current literature review, consultation with practicing
physicians in the Tufts Health Plan service area who are medical experts in the particular field, FDA and
other government agency policies, and standards adopted by national accreditation organizations. Tufts
Health Plan revises and updates Medical Necessity Guidelines annually, or more frequently if new
evidence becomes available that suggests needed revisions.
Medical Necessity Guidelines apply to all fully insured Tufts Health Plan products unless otherwise noted
in this guideline or the Member’s benefit document. This guideline does not apply to Tufts Health Plan
Medicare Preferred or to certain delegated service arrangements. For self-insured plans, coverage may
vary depending on the terms of the benefit document. If a discrepancy exists between a Medical
Necessity Guideline and a self-insured Member’s benefit document, the provisions of the benefit
document will govern. Applicable state or federal mandates will take precedence. Providers in the New
Hampshire service area are subject to CIGNA HealthCare’s provider arrangement for the purpose of
CareLink .
Treating providers are solely responsible for the medical advice and treatment of Members. The use of
this guideline is not a guarantee of payment or a final prediction of how specific claim(s) will be
adjudicated. Claims payment is subject to eligibility and benefits on the date of service, coordination of
benefits, referral/authorization, utilization management guidelines when applicable, and adherence to
plan policies, plan procedures, and claims editing logic.

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