Treatments to Control Drooling (Sialorrhea) (CPB 0265, reviewed 2026-04-16)

REQUIREMENTS: By 2026-04-16 (or immediately upon implementation): 1. Billing team must update prior authorization protocols in billing system to require documentation of BOTH criteria before approving CPT 42440, 42507, 42509, 42510, 42665, and 69676: (a) evidence of excessive drooling with significant morbidity (skin maceration, poor oral hygiene, or dehydration), AND (b) documented failure of physical therapy and drug therapy. 2. Add authorization rules to deny or route for manual review any claims for: - Transoral submandibular ganglion neurectomy (no specific CPT code listed) - CPT 36470 (sclerotherapy for incompetent vein) - CPT 49185 (sclerotherapy of fluid collection) - Kinesio taping (no specific code) Mark these as "experimental/investigational—not covered." 3. Providers/front desk staff must update encounter forms and clinical templates to require documentation of: (a) severity of drooling and type of morbidity present, and (b) specific conservative treatments attempted (physical therapy modality, specific anti-cholinergic drugs and dosages, duration of trial). 4. Update denial letter templates to explain that surgical drooling procedures require both medical necessity criteria; denials should reference the two-part requirement and specify which criterion was not met. 5. Related policy reference: Ensure CPT 42550 (sialography) and related diagnostic codes (70390, D0310) are recognized as supporting documentation codes, not primary billing codes. CONSEQUENCES: Claims submitted for covered surgical codes without documentation of both criteria will be denied. Claims for experimental procedures (ganglion neurectomy, sclerotherapy, kinesio taping) will be automatically denied per policy.