69676
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
9.45
Facility
$746.84
Non-Facility
$746.84
Documentation Required
- Documented evidence of excessive drooling associated with significant morbidity (examples given: skin maceration, poor oral hygiene, dehydration).
- Documentation of failure to adequately respond to appropriate conservative measures, specifically physical therapy and drug therapy (record of therapies tried, duration, responses, adverse effects or reasons for discontinuation).
- Documented diagnosis using appropriate ICD-10 codes when selection criteria are met (policy lists K11.1 and K11.7 as covered diagnoses).
- Clinical notes and pre-operative evaluation justifying the selection of the specific surgical procedure (including consultations as clinically applicable — e.g., otolaryngology, dentistry, speech therapy) to support that member meets selection criteria.
Key Coverage Criteria
- The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Parotid duct diversion, bilateral, with excision of one submandibular gland.
- The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Parotid duct diversion, bilateral, with excision of both submandibular glands.
- The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Parotid duct diversion, bilateral, with ligation of both submandibular ducts.
- The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Relocation of the submandibular ducts, with or without removal of sublingual glands.
- The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Tympanic neurectomy or chorda tympani neurectomy.
- Covered ICD-10 diagnoses (when selection criteria are met): K11.1 (Hypertrophy of salivary gland).
2 Active Policies
AETNA-CPB-0265 — Surgical Treatments to Control Drooling (Sialorrhea)
REGENCE-SUR165 — Surgical Treatments for Hyperhidrosis
Related Codes
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