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Cleft Insurance Codes - A View From Doctors Side

The document below comes from the

   American Society Plastic and Reconstructive Surgeons


This is their recommendations and explanations for insurance coverage. How the doctor sees it. Perhaps it will help you in your quest to get insurance to cover your procedures. Remember, repairs are being done as reconstructive surgery not plastic surgery. They are medically necessary.


Recommended Criteria for Third-Party Payer Coverage


The American Society of Plastic and Reconstructive Surgeons (ASPRS) is the largest organization of plastic surgeons in the world. Requirements for membership include certification by the American Board of Plastic Surgery.

As the umbrella organization for the specialty, ASPRS represents 97 percent of 5,000 of the board-certified surgeons practicing in the United States and Canada. It serves as the primary educational resource for plastic surgeons and as their voice on socioeconomic issues. ASPRS is recognized by the American Medical Association, (AMA) the American College of Surgeons (ACS) and other organizations of specialty societies.


Cleft Lip--

A cleft lip is a birth defect that result in unilateral or bilateral opening in the upper lip between the mouth and the nose. It causes disfigurement and makes feeding difficult.


Cheiloplasty, or cleft lip repair, is performed to close the opening in the lip caused by this birth defect. If the cleft is bilateral, closure may be performed on both sides simultaneously, or the surgeon may repair the lip one side at a time in separate surgeries. In some case, when the deformity is severe, a preliminary operation referred to as a lip adhesion may be done.

Cleft Palate--

A cleft palate is a birth defect characterized by an opening in the roof of the mouth, caused by a lack of tissue development. In this case, the mouth and nasal cavity, normally separated by the palate, are open to each other. The cleft can extend from the hard palate in the front of the mouth to the soft palate near the throat. Left unrepaired, a cleft palate will create feeding difficulties and lead to speech impediment, hearing loss and abnormal dental development.


Palatoplasty, or cleft palate repair, is performed to close such an opening in the palate. Many surgeons prefer to close the posterior palate either at the time of lip repair or when the child is one year of age or older. Approximately three to six months later, the entire palate is repaired by lengthening it to close the defect and prepare it for speech.

For a child with cleft lip and palate, the anomalies can be either mild or severe and can cause complex distortion of facial structures. The number of operations necessary to achieve a satisfactory final result depends on the type and degree of the patient's cleft and associated problems. Adult patients who underwent repair of a cleft lip or palate
before current techniques were developed may have marked residual deformities and impairment that require surgical reconstruction to approximate a normal appearance and function.


For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June 1989:

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, development abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.


Primary surgery, cleft lip, ICD-9: 749.1,749.2

Cleft lip repair is generally performed in a hospital under general anesthesia as an inpatient procedure. There are two general surgical approaches. In a technique known as rotation- advancement lip repair, the surgeon makes an incision on either side of the nostrils, extending from the lip into the nostril. Working through the incision, the surgeon opens the lip completely, rotates the pink outer portion downward, and advances tissue from the cheek into the defect to eliminate the cleft. In another method, referred to as triangular flap repair, the surgeon makes incisions
to form small skin flaps between the lip and nose. These flaps overlap and interlock to close the defect, restore muscle function, create needed height in the flap, and form a cupid's bow. CPT: 40701,40702,40761

Primary surgery, cleft palate, ICD-9: 749.0,749.2

Palatoplasty is usually performed in a hospital under general anesthesia as an inpatient procedure. Methods for repairing a cleft palate may vary widely in terms of when they are performed and what techniques are used. In a typical repair, incision are made in the palate to provide sufficient tissue to close the defect. This tissue is moved to the mid-line or the center of the mouth to reconstruct the palate, join the muscles and provide adequate length to the soft palate. CPT: 42200,42205,42210

Secondary surgery, ICD-9: 749.0,749.1,749.2

When there has been unfavorable healing of a cleft lip repair, secondary correction of the lip can be accomplished by re-creating the defect and closing it with a more satisfactory alignment. Additional procedures, such as transplanting tissue from the lower lip to the upper lip, may be required for particularly severe cleft lip deformities. CPT: 40720,40761

Patients with cleft lip deformities of the nose. Cleft lip rhinoplasty is necessary to improve nasal function and correct the distortion. In the case of a severe nasal deformity, reconstructive rhinoplasty may be done in the child's early years. However, in other cases it is recommended that the operation be performed in the child's middle teenage years, when the nose has attained its maximum growth. Secondary surgery to achieve optimum reconstruction is common. CPT: 30400,30410,30520,30620

Repair of a complete cleft palate, one that extends from the lip to the throat, is generally performed in two operations. However, later revisions are often needed by children because of scarring and impaired growth of the palate.

Communication (fistula) between the oral cavity and the nose or maxillary sinus is a sequela of cleft palate procedures and requires surgical closure. An additional operation, a bone graft commonly from the skull, hip or rib, may be required to replace missing bone in the roof of the mouth, or gums (alveoloplasty). CPT: 30580,42210,42215,42220,42227,42235, 42260

Cleft palate patients may also have abnormal movement of the speech mechanism in the back of the throat. As they grown older and begin to speak, air may escape from the nostrils in an abnormal way and cause hypernasality. A surgical procedure known as a pharyngeal flap - palatoplasty is done to correct this deformity and permit normal speech. CPT: 42225,42226

Anomalies of the upper jaw (maxilla) develop as well, sometimes requiring surgical correction in the teenage years. If the maxilla is deficient (hypoplastic), it may require expansion of realignment by osteotomy to correct the malocclusion (abnormal jaw relation). CPT: 21204,21205


When cleft lip and palate and secondary deformities are repaired, the indications should be documented by the surgeon in the history and physical and reiterated in the operative note. Chart documentation of the presence of a cleft lip or palate or other secondary deformity should qualify a procedure as medically necessary and, therefore, eligible for insurance coverage.

Photographs are usually taken to document the pre-operative condition and aid the surgeon in planning surgery. In some cases they may record physical signs; however, they do not substantiate symptoms and should only be used by third-party payers in conjunction with less subjective documentation. In circumstances when photographs may be useful to a third-party payer, the plastic surgeon should provide them. The patient, however, must sign a specific release, and confidentiality must be honored. It is the opinions of ASPRS that a board-certified plastic surgeon should evaluate all submitted photographs.


Initial repair of cleft lip and palate deformities is generally performed at any early age, but secondary surgery may be required as the patient grows older and the lip, palate, nasal and jaw structures grow and develop. It is the position of American Society Plastic and Reconstructive Surgeons that both initial and secondary procedures for treatment of cleft lip and palate birth defects should be compensable by third-party payers, regardless of the patient's age.


    Randell, P. A triangular flap operation for the primary repair of
unilateral clefts of the lip. Plast. Reconst. Surg., 23:331, 1959.

    Jackson, I.T. Cleft craft revisited. Adv. in Plast. and Reconst.
Surg., Vol. 1, 1985.

    Hester, R.T., Jr., Jurkiewicz, M.J., Meyer, R., et. a;. Total
reconstruction of end state cleft lip and palate deformity. Plast.
Reconst. Surg., 76:539-551, 1985.

    Marsh J.L. and Galiv, M Maxillofacial osteotomies for patients with
cleft lip and palate. Clin, in Plast. Surg., Vol 16, No. 4 pp. 803-14,

Prepared by the Socioeconomic Committee Approved by American of Plastic and Reconstructive Surgeons Board of Directors Endorsed by American Society of Maxillofacial Surgeons Board of Directors

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