42505
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
6.16
Facility
$410.16
Non-Facility
$574.16
Documentation Required
- Imaging confirmation of the presence, size and location of salivary stones by ultrasound, CT, sialography or direct visualization (sialendoscopy) prior to interventional procedures (multiple study descriptions: e.g., "All patients underwent pre-operative and post-operative screening by routine radiography, sialography, and ultrasound.").
- Clinical documentation of obstructive symptoms (pain and swelling, especially associated with meals), frequency and duration of symptoms, and failure of conservative measures where applicable (descriptions throughout studies describing symptomatic patients and prior conservative treatment failure).
- Documentation that selection criteria are met for the covered ICD-10 diagnoses (the CPB states: "ICD-10 codes covered if selection criteria are met: K11.20 - K11.23 Sialoadenitis [chronic]; K11.5 Sialolithiasis").
Key Coverage Criteria
- Sialolithiasis (salivary gland/duct stones) of the major salivary glands (submandibular and parotid glands).
- Use of CPT 70486 (CT maxillofacial without contrast) and CPT 76536 (ultrasound, soft tissues of head and neck) when performed for the indications listed in this CPB.
- ICD-10 diagnoses covered if selection criteria are met: K11.20 - K11.23 (sialoadenitis [chronic]) and K11.5 (sialolithiasis).
- Stones in which a simple transoral surgical approach is not possible (typically stones in the proximal ducts or in the salivary glands themselves) or when transoral removal fails (UpToDate quote: "For patients in whom a simple transoral surgical approach is not possible (typically stones in the proximal ducts or in the salivary glands themselves) or fails, extracorporeal lithotripsy appears to be effective for stones that are intraductal and less than 7 mm.").
- Intraductal (intraductal/intra-ductal) intraluminal calculi that are intraductal and less than ~7 mm treated by extracorporeal shock wave lithotripsy (ESWL) or by intracorporeal/laser lithotripsy (per cited literature and UpToDate statements).
- Endoscopic (sialoendoscopy) diagnostic evaluation and interventional treatment of obstructive salivary gland disease (including sialolithiasis, strictures/stenosis, mucous plugs and ductal polyps) — indications for endoscopy as listed in the document: "calculus removal that could not be performed by conventional methods; screening of the salivary ductal system for residual calculi after sialolithotomy; positive evidence of ductal dilatation or stenosis on the sialogram or ultrasound examination; [...]
1 Active Policy
AETNA-CPB-0716 — Sialolithiasis (Salivary Stones)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.