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HealthPartners

Coverage criteria policies

Cleft Lip / Cleft Palate

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for cleft lip and cleft palate procedures or treatments as described below.

Coverage

Medical and dental treatment of cleft lip/palate is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Dependent Children (Up to age 26):

Medical and dental treatment to correct a cleft palate defect is covered for dependent children, including oral surgery that may occur in several stages over an extended period of time. Orthodontia is covered when the need for orthodontia is a direct result of the medical condition. Treatment for dependent children age 19 up to age 26 is limited to treatment that was scheduled or initiated prior to the member turning age 19.

Dependent children are also eligible for coverage of oral appliances, such as an obturator, to treat cleft palate.

Speech Therapy:

Dependent Children (Up to age 26):

Speech therapy for children to assist in swallowing or to improve functional speech is considered rehabilitative and is covered for up to one year if needed. Please see the Related Content link at the right for the link to the Speech Therapy – Rehabilitative coverage policy.

Children requiring speech therapy services beyond one year will be evaluated for coverage with the criteria for habilitative speech therapy. Please see the Related Content at the right for the link to Speech Therapy – Habilitative coverage policy.

Adults (Age 19 and over who are not dependents):

Medical and dental treatment of cleft palate is not covered for adults unless they meet the requirements of reconstructive surgery or have impaired function. Adults who have not had initial repair of a cleft lip/cleft palate are not eligible for surgery unless medically necessary, as determined by our medical director or his or her designee.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Minn. Stat. §62A.042

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Policy activity

  • 10/31/1994 - Date of origin
  • 10/31/1994 - Effective date
Review date
  • 09/2016
Revision date
  • 08/22/2016

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