Sialolithiasis (Salivary Stones)

Covered: diagnostic/therapeutic sialendoscopy, ultrasound and high‑resolution non‑contrast CT for nonpalpable stones, and extracorporeal shock wave or intraductal laser lithotripsy only when a simple transoral surgical approach is not possible or has failed; numerous techniques (e.g., elastography/MRE, contrast‑enhanced ultrasound, endoscopic pneumatic lithotripsy, intraductal steroid irrigation, sialodochoplasty, SPECT, alpha‑blockers, AR concretion visualization, MUC8 biomarker, trans‑cervical/trans‑oral submandibular stone removal, ultrasound‑guided sialo‑irrigation) and several CPT codes are considered experimental/investigational and not covered. Key requirements: services are covered only if the policy’s selection criteria are met (ICD‑10 K11.20–K11.23, K11.5); sialendoscopy performed with another salivary duct/gland surgery is considered incidental and not separately reimbursable.

"Intraductal steroid irrigation as an adjunct to sialendoscopy for the treatment of sialadenitis without sialoliths is experimental and investigational."