CommercialCoverageLow impact
Sialolithiasis (Salivary Stones) (CPB 0716, reviewed 2026-10-15)
Aetna·ENT (Ear, Nose & Throat), Oral & Maxillofacial Surgery, General Surgery·Medical Policy
We identified it
Oct 19, 2026
Summary
Aetna's Clinical Policy Bulletin 0716 (reviewed 2026-10-15) establishes coverage criteria for sialolithiasis (salivary stone) treatment. The policy covers sialendoscopy, extracorporeal shock wave lithotripsy, intraductal laser lithotripsy, and imaging modalities when criteria are met, while designating numerous alternative approaches (alpha-blockers, pneumatic lithotripsy, sialodochoplasty, elastography, and others) as experimental/investigational and therefore not covered.
Action Required
Verify current applicability of this policy by confirming whether the practice's billing system and documentation processes align with Aetna's current coverage determinations for sialolithiasis treatment. Specifically: (1) Billing team should confirm that claims for covered procedures (sialendoscopy, ESWL, intraductal laser lithotripsy) for ICD-10 codes K11.20–K11.23 and K11.5 are submitted with appropriate imaging codes (70486, 76536); (2) Verify that experimental modalities listed in the policy (pneumatic lithotripsy, sialodochoplasty, alpha-blockers, elastography, and others) are not being billed for sialolithiasis cases, as these will be denied; (3) Confirm whether prior authorization is required for covered procedures by consulting the Aetna plan documentation, as the bulletin does not specify authorization requirements; (4) Review the exclusion note that sialendoscopy performed in conjunction with other salivary duct/gland surgery will not be reimbursed separately. No future deadline is stated in the source.