Sialolithiasis (Salivary Stones) — CPB 0716 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0716 governing sialolithiasis (salivary stones) coverage, effective October 16, 2025. Here's what billing teams need to know before claims go out the door.

This update to the Aetna sialolithiasis coverage policy clarifies medical necessity criteria for sialendoscopy, lithotripsy, and diagnostic imaging — while expanding its list of experimental and investigational procedures to 15 items. The policy covers CPT codes including sialolithotomy codes 42330–42340, elastography codes 76391, 76982, and 76983, and salivary gland imaging codes 78230–78232. If your practice performs salivary gland procedures and bills Aetna, this policy directly shapes what gets paid and what triggers a claim denial.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Sialolithiasis (Salivary Stones)
Policy Code	CPB 0716 Aetna
Change Type	Modified
Effective Date	October 16, 2025
Impact Level	Medium
Specialties Affected	Oral and maxillofacial surgery, ENT/otolaryngology, radiology, general surgery
Key Action	Audit active charge capture for sialodochoplasty (CPT 42500, 42505) and elastography codes (76391, 76982, 76983) — these are now explicitly non-covered for sialolithiasis

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Aetna Sialolithiasis Coverage Criteria and Medical Necessity Requirements 2025

The Aetna sialolithiasis coverage policy identifies three treatment modalities as medically necessary. Each one comes with conditions. Meeting the general diagnosis of K11.5 (sialolithiasis) or chronic sialadenitis (K11.20–K11.23) is not enough on its own.

Sialendoscopy — both diagnostic and therapeutic — is covered for chronic sialadenitis and sialolithiasis. There's a critical bundling rule here: if you perform sialendoscopy alongside another salivary duct or gland surgery, Aetna considers the sialendoscopy incidental to the primary procedure. It will not reimburse sialendoscopy separately in that scenario. Bill the primary procedure only.

Extracorporeal shock wave lithotripsy and intraductal laser lithotripsy are covered for patients where a simple transoral surgical approach isn't possible or has already failed. That typically means stones located in the proximal ducts or within the gland itself. The key phrase is "not possible or fails" — you need documentation supporting that the standard transoral approach was attempted or clinically contraindicated. Without that documentation, expect a claim denial.

Ultrasonography (CPT 76536) and high-resolution, non-contrast CT (CPT 70486) are covered for detection of nonpalpable stones in patients suspected of having sialolithiasis. The non-contrast specification matters. Contrast-enhanced ultrasound is explicitly excluded under this coverage policy — more on that below.

Aetna's billing guidelines don't spell out a prior authorization requirement in CPB 0716 itself. That said, prior authorization rules vary by plan and market. Before you assume these services are pre-authorized, verify with the specific Aetna plan. For high-cost procedures like lithotripsy, checking prior auth status before scheduling is basic risk management.

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Aetna Sialolithiasis Exclusions and Non-Covered Indications

This is where the October 16, 2025 update does the most work. Aetna lists 15 procedures as experimental, investigational, or unproven for sialolithiasis. That's a long list — and it covers some approaches your clinical team may view as standard or emerging.

The most billing-relevant exclusions for practices that currently bill these services:

Sialodochoplasty (CPT 42500 and 42505) — not covered for sialolithiasis, whether performed alone or as an adjunct to sialendoscopy. If your practice has been billing 42500 or 42505 alongside sialendoscopy for stone management, those claims are now explicitly non-covered. Audit back claims and update your charge capture now.

Elastography (CPT 76391, 76982, 76983) — both MR elastography and ultrasound elastography are excluded for sialolithiasis evaluation. This includes ultrasound shear-wave elastography for patients undergoing interventional sialendoscopy. If your radiology team has been ordering these as part of a sialolithiasis workup, stop billing them to Aetna for this indication.

Contrast-enhanced ultrasound — excluded. Bill standard ultrasonography (CPT 76536) for diagnostic imaging, not contrast-enhanced variants.

Electro-pneumatic intracorporeal lithotripsy and endoscopic pneumatic lithotripsy — both excluded, alone or as an adjunct to sialendoscopy. These are distinct from the covered extracorporeal shock wave lithotripsy and intraductal laser lithotripsy. Don't conflate them.

Alpha-blockers, intraductal steroid irrigation, trans-cervical stone removal, trans-oral submandibulotomy with duct marsupialization — all excluded. Clinical teams trying newer or minimally invasive approaches should know Aetna won't cover them for this indication.

The real issue here is that some of these exclusions — particularly the augmented reality concretion visualization method and MUC8 biomarker testing — reflect genuinely novel technology. Others, like trans-cervical submandibular stone removal, have been in clinical use for years in some centers. Aetna's position is that the evidence base isn't strong enough for any of the 15. Whether you agree with that clinical judgment or not, the reimbursement reality is the same: bill these and you'll lose.

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Coverage Indications at a Glance

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Aetna Sialolithiasis Billing Guidelines and Action Items 2025

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Sialolithiasis Under CPB 0716

Covered CPT Codes (When Medical Necessity Criteria Are Met)

Not Covered / Experimental Codes

Reference Codes — CPB 0716 General Reference Section

Code	Type	Description	Notes Copy
78230	CPT	Salivary gland imaging	Listed as a general reference code in CPB 0716. The SPECT modality for salivary gland dysfunction is excluded as experimental, but this code is not categorically designated non-covered by the policy.
78231	CPT	Salivary gland imaging; with serial images	Listed as a general reference code in CPB 0716. The SPECT modality for salivary gland dysfunction is excluded as experimental, but this code is not categorically designated non-covered by the policy.
78232	CPT	Salivary gland function study	Listed as a general reference code in CPB 0716. The SPECT modality for salivary gland dysfunction is excluded as experimental, but this code is not categorically designated non-covered by the policy.

Key ICD-10-CM Diagnosis Codes

Note: CPB 0716 does not provide individual sub-descriptions for K11.20–K11.23. All four codes are grouped under "Sialoadenitis [chronic]" in the source policy.

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