Aetna Facial Nerve Paralysis Coverage Update

inv-01: Medically necessary diagnostic and therapeutic interventions

Covered when the following specific conditions are met:

Diagnostic tests considered medically necessary: Blink reflex testing for diagnosis of Bell's palsy is medically necessary.

Supported by policy statement listing blink reflex testing as medically necessary.

Eyelid implant: Gold weight eyelid implants are medically necessary for treatment of Bell's palsy-related lagophthalmos.

Supported by policy statement listing gold weight eyelid implants as medically necessary.

Facial reconstructive surgery (anastomosis/grafts/muscle transfer)

Eligibility criteria: (1) Facial paralysis has persisted for more than 12 months; and (2) Facial paralysis has resulted in impaired functional deficit in mastication, speech, or vision; and (3) There is no reasonable likelihood of spontaneous return of function as determined by electromyography or electroneuronography.duration: > 12 months
These three elements must all be present.

inv-02: Experimental and investigational (Not covered)

The following are considered experimental and investigational for the diagnosis or treatment of Bell's palsy:

Diagnostic tests considered investigational: Genetic analysis of facial muscle specimens; measurement of blood total/native thiol and disulphide activity as a pathogenetic marker; neuromuscular ultrasound.

Effectiveness not established.

Therapies considered investigational: Acupuncture; anti-viral therapy; botulinum toxin; electrical stimulation; facial nerve decompression; facial retraining therapy; hyperbaric oxygen therapy; infrared therapy; intra-tympanic steroid injection; Kinesio taping; laser acupuncture; nerve growth factor; neural therapy; peripheral blood mononuclear cells and platelet-rich plasma transplantation; photobiomodulation; proprioceptive neuromuscular facilitation; transcranial magnetic stimulation; vitamin B-12 therapy.

Listed as experimental/investigational due to lack of established effectiveness.

inv-03: Medical (steroids ± antivirals) – evidence summary

Summary of evidence-based coverage considerations

Medical therapy for new-onset Bell's palsy: Offer systemic corticosteroids initiated early (within ~72 hours to 7 days of symptom onset) to increase the probability of complete recovery; antivirals alone do not improve recovery, and antivirals added to steroids provide at most modest and inconsistent additional benefit.timing: within 72 hours to 7 days

Based on Sullivan et al (randomized factorial trial) and meta-analyses showing corticosteroid benefit and limited antiviral benefit.

inv-04: Physical therapy (exercises, electrostimulation, acupuncture)

Physical therapy / rehabilitation

Physical therapies: Tailored facial exercises (mirror, EMG biofeedback, neuromuscular re-training) have low- to moderate-quality evidence of benefit for chronic or moderate paralysis and may reduce sequelae in some acute cases; electrostimulation and acupuncture lack high-quality evidence of consistent benefit.varies by study

Based on systematic reviews (Teixeira et al) and small trials; evidence heterogeneous and generally low quality.

inv-05: Surgery and reanimation – evidence and timing

Surgical management and reanimation

Surgical decompression: Randomized trial evidence for surgical decompression in Bell's palsy is very limited and of very low quality; reported risks include sensorineural hearing loss and vertigo. Consider decompression only in well-selected patients with objective evidence and after counseling about risks.consider only in well-selected patients

Cochrane review found very low-quality evidence from small trials.

Reconstructive procedures for long-standing paralysis: Reconstructive options include early nerve repair/grafting when timely, cross-facial nerve grafting with staged free functional muscle transfer, single-stage masseteric nerve–driven free muscle transfer, and temporalis or masseter transpositions; selection depends on duration (>12 months), etiology, patient factors, and goals.typically after ~12 months without recovery for consideration of reanimation surgery

Based on surgical series and expert reviews describing staged approaches and indications.

inv-06: Surgical reanimation: evidence summaries

Surgical reanimation approaches and indications summarized from case series and reviews:

Surgical reanimation general: Immediate nerve repair/grafting is favored when onset is recent and target muscles remain viable; for irreversible unilateral complete palsy a staged approach (cross-facial nerve grafting followed by free functional muscle transfer) is commonly used; in patients with limited life expectancy, masseteric or temporalis transfers may be preferred.

Recommendations based on expert reviews and large case series.

Alternative single-stage option: Single-stage free gracilis transfer innervated by the masseteric nerve can produce voluntary smile recovery within months and has been reported with satisfactory outcomes in small series.

Supported by small case series (Momeni, Chuang).

Bilateral palsy: Bilateral free gracilis transfers using masseteric nerve branches are reported options for bilateral facial palsy.

Reported in surgical series and reviews.

inv-07: Adjunctive and conservative therapy: evidence summaries

Adjunct and conservative treatments with summarized findings:

Corticosteroids for Bell's palsy: Systemic corticosteroids are effective and represent standard initial therapy; adding antivirals does not consistently improve outcomes except possibly in some severe cases.

Cochrane and randomized trial evidence support corticosteroid benefit (Sullivan et al, Gagyor et al).

Intra-tympanic steroids: Combined systemic and intra-tympanic corticosteroids may reduce non-recovery in some studies, particularly with daily ITST regimens, but methods vary and further RCTs are needed.

Meta-analysis of RCTs and cohorts (Fujiwara et al) suggests potential benefit with daily ITST.

Acupuncture +/- vitamin B12: Acupuncture trials are heterogeneous and at high risk of bias; acupuncture combined with vitamin B12 showed lower incomplete recovery rates in some small studies but evidence quality is limited.

Systematic reviews/meta-analyses report inconsistent findings and methodological limitations.

inv-08: Diagnostics and biomarkers

Diagnostic modalities evaluated:

Neuromuscular ultrasound: Ultrasound can detect facial nerve enlargement with reported sensitivity ~75% and specificity ~70%; current technique lacks sensitivity for routine diagnosis but may be useful for assessment or follow-up.sensitivity ~75%

Pilot study (Tawfik et al) reported these performance characteristics.

Thiol/disulphide biomarker: Preliminary study found lower total and native thiol and higher disulphide levels in Bell's palsy with a reported disulphide cut-off of 18.95; these findings require validation.disulphide > 18.95

Prospective study (Babademez et al) — preliminary research.

inv-09: Facial nerve decompression — selection criteria

Surgical facial nerve decompression (selected statements from literature): Covered when ALL of the following are met

Decompression candidate criteria: 1) Complete facial paralysis or severe dysfunction (eg, House-Brackmann grade V–VI); and 2) Electrophysiologic testing consistent with severe degeneration (eg, >90% on electroneuronography and absent voluntary EMG within ~14 days); and 3) Timing appropriate for the chosen approach — middle cranial fossa decompression (MFD) ideally within 14 days for best outcomes (some series suggest benefit if performed within 90 days when earlier surgery is not possible); and 4) Patient counseled on risks (including reported risk of sensorineural hearing loss) and that return of maximal function may be delayed up to 12 months.ENoG > 90% degeneration; timing: MFD ≤14 days (optimal)

Derived from Andresen, Casazza, Berania observational series and reviews.

inv-10: Post-paralytic synkinesis — staged care

Management of post-paralytic synkinesis: consider the following sequence

Synkinesis management sequencing: 1) First-line: chemodenervation with botulinum toxin and neuromuscular re‑training; and 2) If refractory: consider selective myectomy, selective neurectomy, or reanimation procedures (eg, free muscle transfer) individualized to the patient; and 3) Surgical options should be considered after multidisciplinary discussion and when benefits outweigh limited evidence and potential need for revision surgery.N/A

Based on systematic review and clinical practice recommendations that describe surgery as third-line.

inv-11: Complementary and experimental interventions — informational

Complementary, experimental, or low-quality evidence interventions noted in literature

Nonstandard interventions with limited evidence: Nerve growth factor (NGF), thiol/disulphide biomarker measurement, neural therapy, acupuncture (including laser/acupoint techniques), Kinesio taping, photobiomodulation, peripheral blood mononuclear cell + PRP transplantation, proprioceptive neuromuscular facilitation, and other novel modalities have preliminary or low-quality evidence only and require further well-designed trials.N/A

Informational summary of heterogeneous, generally low-quality literature.

inv-12: Consideration for selective neurectomy

Selective neurectomy may be considered only when ALL of the following are met:

Required conditions: 1) Patient has post‑paralytic synkinesis producing functional impairment or reduced quality of life; and 2) Adequate documented trials of first‑line therapies (botulinum toxin chemodenervation and neuromuscular re‑training) have been attempted without sufficient benefit; and 3) Patient has been counseled about limited evidence, potential complications, and variable success rates; and 4) Multidisciplinary consideration of alternative surgical options has occurred.

Based on systematic review findings and international recommendations that surgery is third‑line and should be individualized.

Specific procedures, devices, and supplies that are listed as experimental and investigational in this bulletin are excluded from coverage for the indications addressed. Examples include (but are not limited to) acupuncture; anti‑viral therapy; botulinum toxin; electrical stimulation; facial nerve decompression; facial retraining therapy; hyperbaric oxygen therapy; infrared therapy; intra‑tympanic steroid injection; Kinesio taping; laser acupuncture; nerve growth factor; neural therapy; peripheral blood mononuclear cells and platelet‑rich plasma transplantation; photobiomodulation; neuromuscular ultrasound; genetic analysis; and measurement of blood thiol/disulphide activity. Relevant not‑covered HCPCS/CPT supply and device codes are listed in the coding section and correspond to items on the investigational list.

Osteopathic and chiropractic manipulation have been used in some case reports and small series, but the available literature does not provide sufficient scientific evidence to support their effectiveness for Bell’s palsy. Accordingly, these manual therapies are considered experimental and investigational for this indication and are not supported as covered treatments.

Routine use of electrical nerve stimulation for Bell’s palsy is not recommended. Small trials and reviews do not demonstrate clear added benefit over multimodal physiotherapy or spontaneous recovery, and controlled trial evidence and comprehensive safety data are lacking; therefore electrical stimulation is listed as experimental and investigational for this indication and related stimulator supplies are included among non‑covered HCPCS codes.

There is very low‑certainty evidence from randomized trials regarding early surgical intervention for Bell’s palsy; existing systematic reviews and RCTs are insufficient to determine benefit or harm. Because spontaneous recovery or medically supported recovery occurs in most cases, the evidence does not support routine early surgery and surgical approaches remain investigational except in carefully selected circumstances with appropriate objective testing and counseling.

Selective neurectomy and other synkinesis‑directed surgeries are not recommended as first‑line therapy. These procedures should not be performed without prior discussion of risks and recognition that long‑term outcomes data are limited; current practice recommendations describe selective myectomy/neurectomy as a third‑line option after less invasive therapies have been attempted.

Any procedure or therapy appearing on the experimental/investigational list (for example, acupuncture, botulinum toxin, electrical stimulation, hyperbaric oxygen, PRP injections, neuromuscular ultrasound, genetic testing, photobiomodulation, etc.) is considered not established for the indications in this bulletin and therefore is not medically necessary for treatment of Bell’s palsy unless later evidence demonstrates effectiveness.

High‑quality evidence from pooled trials indicates that anti‑herpes simplex antivirals when used alone do not provide a significant benefit over placebo for complete recovery in Bell’s palsy. As a result, antivirals without concurrent corticosteroid therapy are considered not medically necessary as sole therapy for this condition.

Systematic reviews and meta‑analyses of acupuncture and related therapies show heterogeneous methods, high risk of bias, and incomplete safety reporting. While some pooled analyses report higher ‘effective response’ rates, the overall evidence is insufficient to conclusively support routine use; therefore acupuncture and similar complementary therapies are considered experimental and investigational for Bell’s palsy.

Routine surgical decompression for early management of Bell’s palsy is not supported by high‑certainty randomized trial evidence. Meta‑analyses and reviews report very limited and low‑certainty data; thus decompression is not established as standard care except in carefully selected patients who meet objective electrodiagnostic and timing criteria and who have been counseled about potential risks.

Selective neurectomy performed without documented prior conservative management (including documented trials of botulinum toxin chemodenervation and neuromuscular retraining), and without individualized counseling regarding limited evidence and possible complications, is considered not medically necessary for treatment of post‑paralytic synkinesis.

Prior Authorization, Documentation, and Step Therapy

Prior Authorization

Prior Authorization Required for Surgical/Interventional Codes

Prior authorization is required for surgical and interventional CPT/HCPCS codes related to facial reconstructive and reanimation procedures. Requests should include supporting clinical documentation demonstrating that selection criteria are met before services are scheduled.

Prior authorization required for complex facial reconstructive/reanimation CPT/HCPCS codes
Authorization must document that selection criteria (e.g., duration >12 months, functional deficit, lack of spontaneous recovery on EMG/ENoG) are met

Prior Authorization

Prior Authorization for Facial Reanimation

Prior authorization should be obtained for elective facial reanimation surgeries. Given limited high-quality randomized evidence, authorization is appropriate only when documentation supports medical necessity and conservative measures have been attempted or are not reasonable.

Authorization expected for cross-facial nerve grafting, free functional muscle transfer, hypoglossal or masseteric nerve transfers, temporalis transposition, and related microvascular procedures
Include rationale for surgery (cause of lesion, duration, prior treatments, functional deficits)

Prior Authorization

Authorization When Surgical Decompression Is Proposed

When facial nerve decompression is proposed, prior authorization must include objective evidence of severe paralysis and electrophysiologic testing supporting irrecoverable nerve degeneration. Documentation should justify surgical timing and approach.

Required: House-Brackmann grade, duration since onset, and ENoG showing >90% degeneration or absent voluntary EMG when applicable
Document proposed surgical approach (middle cranial fossa vs transmastoid), timing from symptom onset (e.g., ≤14 days vs >14 days), and expected benefits/risks

Prior Authorization

Prior Authorization Expectation for Selective Neurectomy

Selective neurectomy (SN) is considered a third-line, adjunctive surgical option for post-paralytic synkinesis and requires prior authorization only after failure or inadequate response to first-line therapies. Provide documentation of prior non-surgical management and rationale for SN.

Authorization expected only after documented trials of botulinum toxin (chemo-denervation) and neuromuscular re‑training
Document targeted symptoms (synkinesis type), prior Botox dosing/frequency and response, duration of non-surgical therapy, and planned extent of neurectomy/myectomy

Denial Risk

Experimental/Investigational Exclusions Trigger Denial

Procedures and therapies designated as experimental or investigational will be denied. Prior authorization requests for these services should not be approved unless new, high-quality evidence justifies coverage.

Services considered experimental/investigational: genetic analysis of facial muscle specimens, neural therapy, neuromuscular ultrasound (for diagnosis), blood thiol/disulphide testing, injection of platelet-rich plasma for this indication, photobiomodulation, acupuncture modalities listed
Facial nerve decompression is listed among investigational treatments for Bell's palsy in portions of the policy — evaluate per indication and evidence; some decompression indications (selected trauma/time-limited) may be considered with documented criteria

Note

Surgical Intervention Evidence Limited — Authorization Requires Careful Justification

Surgical interventions for Bell's palsy and other causes of facial paralysis have limited high-quality randomized evidence. Authorization decisions should reflect the uncertain benefit and the need for individualized clinical justification.

Randomized evidence is very limited (small trials, low quality) and observational data guide much of current practice
Authorization requires clear documentation of failure of conservative/medical therapy and objective measures supporting the anticipated benefit

Note

Outcome Expectations for Alternative Motor Nerve Procedures

When alternative motor-nerve–based procedures (e.g., temporalis transposition, hypoglossal or accessory nerve neurotization) are proposed, prior authorization should set outcome expectations: these approaches may restore movement but often do not produce a spontaneous smile and outcomes differ from facial-nerve–based reinnervation.

Document patient counseling about expected functional outcomes (e.g., temporalis transfers may produce voluntary but not spontaneous smile)
Indicate reasons for selecting motor-nerve–based procedure (e.g., comorbidities, limited life expectancy, prior failed procedures)

Documentation Required

Objective Electrophysiologic Confirmation Recommended Prior to Decompression

Objective electrophysiologic confirmation is recommended before authorizing facial nerve decompression. ENoG and EMG findings, when documented, should support the absence of spontaneous recovery potential.

Include electroneuronography (ENoG) percent degeneration and EMG showing absent voluntary motor unit potentials where applicable
Specify timing of tests relative to symptom onset and correlate with proposed surgical timing

Note

Evidence Limitations May Affect Authorization

Evidence limitations (heterogeneity, small studies, observational designs) may affect authorization outcomes. Decisions should be individualized, and surgery generally considered third-line after noninvasive options have been exhausted.

Authorization may be denied or limited when documentation does not address evidence gaps or fails to demonstrate prior appropriate therapies
Consider multidisciplinary evaluation and second-opinion documentation when evidence is limited

Documentation Required

Required Documentation for Facial Reconstructive Surgery

For facial reconstructive surgery (anastomosis, fascia slings, muscle transposition, cross-facial nerve grafting with microvascular muscle transfer), provide comprehensive operative planning and prior-treatment documentation to support medical necessity.

Document duration of paralysis (>12 months for chronic procedures) and absence of meaningful spontaneous recovery
Functional impairment described (mastication, speech, vision), prior EMG/ENoG results demonstrating lack of recovery potential, and rationale for chosen reconstructive technique
Include prior non-operative therapies and outcomes, patient counseling regarding expected results and staged procedures

Documentation Required

Required Clinical Documentation Elements

Authorization requests must include key clinical documentation elements to establish medical necessity and appropriate sequencing of care.

Timing of treatment initiation (e.g., within 72 hours or 7 days for medical therapy where applicable) and time since onset of paralysis
Diagnostic exclusion of alternate causes (e.g., zoster sine herpete) when relevant, and test results (ENoG, EMG, imaging)
Functional status measures (House-Brackmann grade, Yanagihara or eFACE scores), and documentation of impact on activities (mastication, speech, vision)

Documentation Required

Required Clinical Documentation for Surgical Reanimation

For surgical reanimation requests, include detailed clinical history and objective findings demonstrating appropriateness of the procedure and timing.

Onset timing and etiology of lesion; prior treatments and responses (medical, Botox, re-training)
Objective functional status (House-Brackmann grade), electrophysiologic testing results, and imaging when performed
Rationale for selected reanimation technique (cross-facial grafting vs masseteric or hypoglossal transfers), staged treatment plan, and expected functional outcomes

Documentation Required

Required Clinical Documentation for Decompression Consideration

For consideration of decompression surgery, include documentation of the degree and timing of paralysis plus electrophysiologic testing that supports the need for decompression versus continued medical management.

House-Brackmann grade at presentation, timing since onset, and indication for decompression approach (MFD vs TMD)
ENoG percent degeneration (e.g., >90%) or absent voluntary EMG within recommended windows, and imaging when performed
If decompression is delayed, document reason and expected benefit given literature suggesting timing influences outcomes

Documentation Required

Suggested Documentation for Selective Neurectomy (SN)

For selective neurectomy requests, suggest documentation elements that justify progression to surgery after conservative measures and that define the planned procedure and expected outcomes.

Document prior use of botulinum toxin (Botox) with dates, doses, intervals, and clinical response
Detail neuromuscular retraining efforts (duration, therapy goals, objective measures), synkinesis classification (type II/III), and failure or insufficiency of prior treatments
Specify targeted branches for neurectomy/myectomy, anticipated reduction in Botox need, and plans for adjunctive reanimation if applicable

Step Therapy

Conservative Management Expected Before Surgery

Conservative management is expected before considering elective facial surgery. There is no single mandated step-therapy algorithm, but non-surgical options should be trialed and documented prior to authorization for invasive procedures.

First-line conservative measures include facial exercises, massage, neuromuscular re‑training, and appropriate medical therapy (see medical sequencing)
Document trials of conservative care and objective responses; surgical referral without reasonable conservative attempts should be justified

Note

Medical Therapy Sequencing

Medical therapy sequencing: early systemic corticosteroids are supported for new-onset Bell's palsy; antivirals alone lack clear benefit but may be considered in combination with corticosteroids in selected severe cases.

Recommend early prednisolone (within 72 hours) for Bell's palsy as first-line medical therapy
Antivirals (acyclovir/valacyclovir) do not add clear benefit alone; combination with corticosteroids may offer incremental benefit in some analyses particularly for severe palsy

Step Therapy

Step Therapy: Medications for Bell's Palsy

Step therapy for medications in Bell's palsy: systemic corticosteroids are the initial therapy; antivirals may be added in severe presentations but are not routinely required.

Initial therapy: systemic corticosteroids (prednisone/prednisolone) within recommended window
Reserve adding antiviral therapy for severe cases or based on treating clinician judgment and documented rationale

Step Therapy

Triage of Synkinesis Therapies

Triage of therapies for post-paralytic synkinesis should prioritize non-surgical options (chemo-denervation and neuromuscular retraining). Surgical options, including selective neurectomy, are third-line and require documentation of prior therapies and limited response.

First-line: botulinum toxin injections (Botox) and structured neuromuscular re‑training
Consider SN, myectomy, or reanimation procedures only after adequate trials of first-line therapies with objective documentation of persistent disabling synkinesis

Step Therapy

Step Therapy Pathway

Step therapy pathway for synkinesis: require documented progression through first-line non-surgical interventions before authorizing surgical interventions; selective neurectomy should be reserved for refractory cases.

Step 1: Chemo-denervation with botulinum toxin and documented response assessment
Step 2: Neuromuscular retraining for an adequate course with objective measures (eFACE, FaCE, House-Brackmann)
Step 3: Consider selective neurectomy, myectomy, or reanimation only if Steps 1–2 fail or are contraindicated, with detailed justification

Definitions and Background

Bell’s palsy is an acute idiopathic facial nerve (cranial nerve VII) paresis characterized by rapid onset unilateral facial weakness over 24–72 hours. Most patients experience spontaneous recovery within approximately 6 months, although recovery may be delayed in some populations (for example, persons with diabetes). Diagnosis is one of exclusion; electrophysiologic testing such as blink reflex testing and EMG/ENoG can aid in diagnosis and provide prognostic information. Blink reflex testing is specifically listed as a medically necessary diagnostic modality in this policy.

Bell's palsy

DefinitionAcute idiopathic facial paresis — rapid onset facial paralysis of cranial nerve VII

Typical courseUsually self‑limiting with majority recovering spontaneously within 6 months

PresentationAbrupt unilateral facial weakness over 24–72 hours; may include ear pain, reduced taste, and hyperacusis

Diagnostic aidsBlink reflex testing and facial EMG have been used; blink reflex sensitivity ~81% and specificity ~94%

Medically necessary facial surgery criteria

When surgery is considered necessaryWhen facial paralysis has persisted > 12 months, causes impaired mastication/speech/vision, and EMG/ENoG indicates low likelihood of spontaneous recovery

Covered procedures examplesAnastomosis with other cranial nerves, fascia slings, muscle transposition, cross‑facial nerve grafting with microvascular muscle transfer

Timing guidanceIf any early return is noted on EMG, delay further intervention; start consideration if no return at 12 months

Early treatment

Initiation windowWithin ~72 hours (Sullivan et al) up to 7 days (Hato et al) of symptom onset

Primary recommended therapyEarly systemic corticosteroids (prednisolone) increase probability of complete recovery

Antivirals roleAntivirals alone show no clear benefit; may provide modest additional benefit when combined with steroids in some analyses

Cross-face nerve graft (CFNG)

Procedure descriptionCross‑face nerve graft (CFNG) is a staged nerve graft using the contralateral facial nerve to reinnervate paralyzed facial muscles, often followed by free functional muscle transfer

Typical stagingInitial CFNG followed by gracilis free flap transfer (commonly ~9 months later) to restore spontaneous mimetic function

IndicationsUsed for long‑standing unilateral irreversible complete palsy when target muscles can still be reinnervated

Cross-face nerve grafting (CFNG)

DefinitionCross‑face nerve grafting: use of contralateral healthy facial nerve via grafting to reinnervate paralyzed facial muscles, often part of staged reanimation with free muscle transfer

GoalRestore spontaneous facial mimetic function and improve symmetry at rest and during expression

Common sequenceCFNG followed by free functional gracilis transfer for dynamic reanimation

Masseteric nerve donor transfer

Donor nerveMotor nerve to the masseter used as donor for single‑stage free functional muscle transfer

Clinical advantageAllows single‑stage reconstruction with earlier voluntary contraction (observed mean ~2.5 months in small series)

Use caseOption when earlier reinnervation desired or when CFNG staging is less suitable due to patient factors

House-Brackmann (HB) scale

PurposeHouse‑Brackmann (HB) scale is a clinical grading system to assess facial nerve function and quantify severity and recovery

UsageReferenced throughout trials and reviews as primary outcome measure for facial function

Scale contextHB grades aid selection for interventions (eg, HB V–VI consistent with severe dysfunction for decompression consideration)

ENoG and EMG

TestsElectroneurography (ENoG) and electromyography (EMG) assess degree of nerve degeneration and voluntary motor unit potentials

Decision roleUsed to determine likelihood of spontaneous recovery and to support surgical decisions (eg, >90% degeneration on ENoG suggests consideration of decompression)

Timing importanceAbsence of voluntary EMG within ~14 days and high ENoG degeneration are cited in decompression candidate criteria

Selective neurectomy (SN)

Procedure intentSelective neurectomy targets specific facial nerve branches to reduce synkinesis and aberrant reinnervation after facial paralysis

Line of therapyDescribed as adjunctive or third‑line after botulinum toxin and neuromuscular re‑training

Evidence summaryData limited; systematic review identified 7 studies (250 patients); most studies used Botox before surgery

Synkinesis

DefinitionSynkinesis: involuntary facial movements occurring simultaneously with voluntary movements after facial nerve paralysis recovery

Clinical impactCan detrimentally affect quality of life and function, prompting staged management

Management contextFirst‑line: botulinum toxin and neuromuscular retraining; surgical options (including SN) considered if refractory

15756	Free muscle or myocutaneous flap with microvascular anastomosis
15758	Free fascial flap with microvascular anastomosis
15840-15845	Graft for facial nerve paralysis
20920-20922	Fascia lata graft
61590	Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of the facial nerve and/or petrous carotid artery
64716	Neuroplasty and/or transposition; cranial nerve (specify)
64742	Transection or avulsion of; facial nerve, differential or complete
64864-64865	Suture of facial nerve
64866-64868	Anastomosis; facial-spinal, facial-hypoglossal or facial-phrenic
64885-64886	Nerve graft (includes obtaining graft), head or neck

0232T	Injection(s), platelet rich plasma, any site (listed as not covered for indications)
76536	Ultrasound, soft tissues of head and neck (neuromuscular ultrasound) - listed under investigational
90867-90869	Therapeutic repetitive transcranial magnetic stimulation treatment codes (listed under investigational)
97014	Application of modality; electrical stimulation (unattended) - investigational for Bell's palsy
97810-97814	Acupuncture codes - listed as investigational
99183	Physician attendance for hyperbaric oxygen therapy - investigational

A4575	Topical hyperbaric oxygen chamber, disposable
A4595	Electrical stimulator supplies, 2 lead, per month (e.g., TENS, NMES)
A4639	Replacement pad for infrared heating pad system, each
E0221	Infrared heating pad system
E0446	Topical oxygen delivery system, not otherwise specified
E0720	TENS device, two lead
E0730	TENS device, four or more leads
E0745	Neuromuscular stimulator, electronic shock unit
G0277	Hyperbaric oxygen under pressure, full body chamber
J0585	Botulinum toxin type A, per unit

OpenPayer

Facial Nerve Paralysis

Coverage Criteria and Evidence Summaries

Prior Authorization, Documentation, and Step Therapy

Codes and Billing

Definitions and Background