CurrentAetnaPolicy 0265

Surgical Treatments to Control Drooling (Sialorrhea)

Defines Aetna's coverage stance and medical necessity criteria for surgical procedures to control refractory excessive drooling (sialorrhea) and lists covered, experimental, and cosmetic designations for specific procedures; applies to Aetna members.

Policy Summary

PayerAetna

PolicySurgical Treatments to Control Drooling (Sialorrhea)

Policy CodePolicy 0265

Change TypeNo material change

Effective DateJun 18, 1998

Next Review DateMar 14, 2024

Key ActionObtain prior authorization and document failed conservative therapies and significant morbidity before surgical treatment is considered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8procedures listed

708systematic review patients

93%4-duct ligation success

82–85%SMGE good-excellent

Coverage Criteria for Surgical Treatment of Sialorrhea

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Covered surgical procedures

The following procedures may be considered medically necessary for members who meet the selection criteria

Allowed procedures: Excision of submandibular gland (with or without parotid duct ligation); Four-duct ligation (ligation of bilateral submandibular ducts and bilateral parotid ducts); Parotid duct diversion, bilateral (Wilke type) — with or without excision of one or both submandibular glands or with ligation of both submandibular ducts; Relocation of the submandibular ducts with or without removal of sublingual glands; Tympanic neurectomy or chorda tympani neurectomy.procedure list

Enumerated procedures from policy

Evidence summaries

Evidence summaries and outcomes for surgical procedures to manage sialorrhea:

Four-duct ligation evidence: Retrospective cohort (38 neurologically impaired children) reported mean duration of effect 52.6 (±20.4) months; caregiver-reported improvement ~80% at 1 month and ~69–71% at 1 year and most recent follow-up; 13 complications in 12 patients including persistent facial swelling and aspiration pneumonia.

Khan et al., 2016

Transoral submandibular ganglion neurectomy (feasibility): Cadaver study (10 cadavers, 20 neurectomies) demonstrated the procedure could be performed bilaterally without injury to the submandibular duct or main trunk of the lingual nerve; authors state further clinical study is needed.

Spock et al., 2015

Transoral submandibular gland excision (small series): Small pediatric series (n=10) reported complete gland removal without vessel or nerve injury, no conversions, and minimum 12 months follow-up; findings are preliminary and require validation.

Hughes & Brown, 2017

Endoscopic transoral neurectomy clinical series: Very small clinical series (n=2 and n=10) reported reduced saliva flow rates and lower VAS scores post-operatively with no complications in short-term follow-up; evidence is preliminary.

Ozturk et al., 2017; Wang et al., 2021

SMGE with or without parotid duct procedures (systematic review/meta-analysis): Systematic review (21 studies, 708 patients) reported good-to-excellent control: SMGE 82% (95% CI:73–89), SMGE+PDL 79% (95% CI:73–85), SMGE+PDR 85% (95% CI:75–92); no significant additional benefit from adding PDL or PDR; reported complications included sialocele, parotitis, dental caries, and dry mouth.

Schild et al., 2021

Long-term outcomes of SGE: Cross-sectional study (n=35) reported significant long-term improvements in VAS, drooling severity and frequency with median follow-up ~313 weeks; 66% would recommend the procedure though some recurrence occurred.

Delsing et al., 2023

Coding — CPT, HCPCS, and ICD-10

CPT codes covered if selection criteria are metCPTCovered

42440	Excision of submandibular (submaxillary) gland
42507	Parotid duct diversion, bilateral (Wilke type procedure)
42509	Parotid duct diversion, bilateral, with excision of both submandibular glands
42510	Parotid duct diversion, bilateral, with ligation of both submandibular ducts (Wharton's ducts)
42665	Ligation salivary duct, intraoral [four-duct ligation]
69676	Tympanic neurectomy

CPT codes not covered for indications listed in the CPBmixedNot Covered

Transoral submandibular ganglion neurectomy

No specific CPT code

Other CPT codes related to the CPBCPT

42450	Excision of sublingual gland
42500	Plastic repair of salivary duct, sialodochoplasty; primary or simple
42505	Secondary or complicated sialodochoplasty
42550	Injection procedure for sialography
70390	Sialography, radiological supervision and interpretation

HCPCS codes covered if selection criteria are metHCPCSCovered

D7981

Excision of salivary gland, by report

Other HCPCS codes related to the CPBHCPCS

D0310

Sialography

ICD-10 codes covered if selection criteria are metICD-10Covered

K11.1	Hypertrophy of salivary gland
K11.7	Disturbances of salivary secretion

Provider Actions — Authorization, Documentation, and Pre-requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of the surgical procedures listed in this policy when the selection criteria are met. Surgical treatments for drooling are governed by this clinical policy; providers should obtain prior authorization per Aetna plan procedures. Policy last reviewed 04/26/2023. Absence of documentation that the member meets the documented policy criteria or coverage terms may trigger denial per plan terms.

Providers must obtain prior authorization before performing surgical treatments to control drooling when selection criteria are met.
Policy last reviewed: 04/26/2023.
Failure to document that the member meets policy selection criteria or coverage terms may result in claim denial.

Step Therapy

Conservative Therapy Required Before Surgery

Conservative measures (physical therapy, behavioral modifications, and appropriate drug therapy) must have been attempted and failed prior to surgical intervention. Providers should document the specific conservative therapies tried, duration of each trial, response to therapy, and reasons for inadequate response or intolerance (e.g., unacceptable side effects from anticholinergic medications). Botulinum toxin injections or other less invasive interventions should be noted if attempted.

Documented trials of physical/behavioral therapy.
Documented trials of appropriate pharmacologic therapy (e.g., anticholinergic agents) and any adverse effects or inadequate response.
Documentation of any botulinum toxin trials or other minimally invasive treatments, if performed.

Documentation Required

Required Clinical Documentation

Providers must submit documentation demonstrating significant morbidity related to excessive drooling and prior trials of appropriate conservative therapies. Documentation should include the diagnosis, detailed description of the morbidity (e.g., skin maceration, poor oral hygiene, dehydration), dates and specifics of prior treatments (types of therapy, doses, durations, response), the specific surgical procedure planned, and postoperative follow-up/outcomes when available. Lack of adequate documentation of morbidity or prior conservative management may be a basis for denial.

Diagnosis and description of morbidity (e.g., skin maceration, poor oral hygiene, dehydration).
Dates, types, doses, and durations of conservative therapies tried and clinical response.
Details of the proposed surgical procedure (CPT/HCPCS codes where applicable).
Postoperative follow-up and outcomes, if available.

Background

Excessive drooling (sialorrhea) commonly occurs in patients with neurologic conditions such as cerebral palsy and can lead to hygiene problems, skin maceration, dehydration, aspiration risk, and interference with therapies. Initial management emphasizes conservative measures — physical and behavioral therapies and anticholinergic medications — which may fail or be limited by side effects. For patients whose drooling is refractory and associated with significant morbidity, surgical options (both gland-ablative and diversionary procedures) may be considered; evidence reports generally favorable symptom control for several procedures but variable complication profiles and differing levels of supporting data.

Definitions — Key Procedures and Terms

Sialorrhea (excessive drooling) — Definition and common causes/impacts

DefinitionExcessive salivary flow (sialorrhea or ptyalism) commonly seen in neurologic disorders; may result from central neurogenic dysfunction (poor deglutition coordination) or peripheral nerve lesions.

Prevalence/contextEstimated to occur in about 10% of patients with cerebral palsy and in other patients with neurologic damage.

Common impactsCan cause significant hygienic problems, skin maceration, dehydration, and may limit speech therapy efforts.

Initial managementAll patients should initially receive physical therapy and behavior modification; anticholinergic medications may be used but often have limiting systemic side effects.

When surgery is consideredSurgical intervention is considered when conservative approaches (physical/behavioral therapy and appropriate drug therapy) fail.

Four-duct ligation — Definition: ligation of bilateral submandibular and parotid ducts

DefinitionFour-duct ligation is the ligation of bilateral submandibular (Wharton's) ducts and bilateral parotid ducts as a minimally invasive surgical approach to reduce salivary flow.

Patient population/example studyDescribed in a retrospective cohort of 38 neurologically impaired pediatric patients with mean duration of effect ~52.6 months and caregiver-reported improvement (80% at 1 month; ~70% at 1 year/long-term).

Complications reportedIn the cited series there were 13 complications in 12 patients; common complications included persistent facial swelling and aspiration pneumonia.

Clinical rolePresented as a simple, effective, and minimally invasive option for management of pediatric sialorrhea when conservative therapy has failed.

Endoscopic transoral submandibular ganglion neurectomy — Definition of the procedure

DefinitionEndoscopic transoral submandibular ganglion neurectomy involves transoral endoscopic ablation or neurectomy of parasympathetic fibers to the submandibular ganglion to reduce stimulation of the submandibular/sublingual glands and decrease saliva production.

Feasibility dataCadaver dissections (10 cadavers, 20 neurectomies) demonstrated the procedure can be performed without injury to the submandibular duct or main trunk of the lingual nerve.

Clinical case seriesSmall clinical reports include a 2-patient adult case-series with 6 months follow-up showing reduced saliva scores and a 10-patient study reporting significant reductions in unstimulated and stimulated saliva flow and VAS scores with 24–36 months follow-up; no complications reported in these small series.

Evidence statusDescribed as preliminary/feasibility with small sample sizes; further well-designed clinical studies are needed to establish effectiveness.

SMGE with PDL or PDR — Definition: submandibular gland excision with parotid duct ligation or rerouting

DefinitionSubmandibular gland excision (SMGE) performed alone or in combination with parotid duct ligation (PDL) or parotid duct rerouting (PDR).

Evidence summarySystematic review (21 studies, 708 patients) reported good-to-excellent control after surgery: SMGE 82% (95% CI: 73–89), SMGE+PDL 79% (73–85), and SMGE+PDR 85% (75–92).

Comparative outcomeNo significant additional benefit was found from adding PDL or PDR to SMGE in the pooled analysis.

Reported complicationsComplications reported across studies included sialocele, parotitis, dental caries, and dry mouth.

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