Subject:
Electronic Salivary Reflex Stimulator
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Electronic salivary reflex stimulator is a noninvasive device which is utilized to increase the production of saliva in patients with xerostomia (dry mouth). It delivers a low-voltage electrical stimulus to the tongue and hard palate via a probe.
Xerostomia may be the result of Sjogren's syndrome, other diseases, medications, or radiation therapy to the head and neck. Conventional and less expensive methods of managing this condition includes constant sipping of water, use of artificial saliva, and use of pharmacologic sialagogues (as well as sialagogues that include sugarless gums, mints and candies) to increase salivary flow.
The Salitron System by Biosonics, Inc. has been approved by the FDA for the treatment of xerostomia secondary to Sjogren's syndrome.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
Electronic salivary reflex stimulator is considered investigational and thus, not medically necessary. There is insufficient data to determine its clinical utility, to evaluate its long-term clinical effectiveness, and to identify the specific members who would benefit from this device.
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Electronic Salivary Reflex Stimulator
Salivary Reflex Stimulator
Dry Mouth, Salivary Stimulator for
Salitron System
Salivary Stimulator
Sjogren's Syndrome, Salivary Stimulator for
Stimulator, Electronic Salivary Reflex
Xerostomia, Salivary Stimulator for
References:
1. Talal N, Quinn JH, Daniels TE. The clinical effects of electrostimulation on salivary function of Sjogren's syndrome patients. A placebo controlled study. Rheumatol Int. 1992;12(2):43-45.
2. Agency for Health Care Policy and Research. Salivary Electrostimulation in Sjogren's Syndrome. Health Technology Assessment Reports, 1990 Number 8.
3. National Guideline Clearinghouse. Symptomatic treatment of radiation-induced xerostomia in head and neck cancer patients. October 15, 1998.
4. Erlichman M. Patient selection criteria for electrostimulation of salivary production in the treatment of xerostomia secondary to Sjogren’s syndrome. Health Technol Assess Rep 1990;(8):1-7.
5. Steller M, Chou L, Daniels TE. Electrical stimulation of salivary flow in patients with Sjogren’s syndrome. J Dent Res 1988 Oct;67(10):1334-1337.
6. Weiss WW Jr, Brenman HS, Katz P, Bennett JA. Use of an electronic stimulator for the treatment of dry mouth. J Oral Maxillofac Surg 1986 Nov;44(11):845-850.
7. Daniels TE, Wu AJ. Xerostomia-clinical evaluation and treatment in general practice. J Calif Dent Assoc 2000 Dec;28(12);933-941.
8. Daniels TE. Evaluation, differential diagnosis, and treatment of xerostomia. J Rheumatol Suppl 2000 Dec;61:6-10.
9. Sjogren’s Syndrome: Treatment. Sjogren’s Syndrome Foundation. http://www.sjogrens.com/syndrome/treatment.html (last accessed 01/07/08).
10. Hargitai IA, Sherman RG, Strother JM. The effects of electrostimulation on parotid saliva flow: a pilot study. Oral Surg Med Oral Pathol Oral Radiol Endod. 2005 Mar;99(3):316-20.
11. Strietzel FP, Martin-Granizo R et al. Electrostimulating device in the management of xerostomia. Oral Dis.2007 Mar;13(2):206-13.
12. Fedele S, Wolff A, Strietzel FP, et al. Electrostimulation for the treatment of dry mouth. Harefuah. 2010;149(2):99-103, 123.
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13. UpToDate. Treatment of dry mouth and other non-ocular sicca symptoms in Sjogren's syndrome. Literature review current through September 2016. Topic last updated April 13, 2015.
14. Pinto A. Management of xerostomia and other complications of Sjogren's syndrome. Oral Maxillofac Surg Clin North Am. 2014 Feb;26(1):63-73.
15. Furness S1, Bryan G, McMillan R, et al. Interventions for the management of dry mouth: non-pharmacological interventions. Cochrane Database Syst Rev. 2013 Sep 5;9:CD009603.
16. Miranda-Rius J, Brunet-Llobet L, Lahor-Soler E, et al. Salivary Secretory Disorders, Including Drugs, and Clinical Management. Int J Med Sci 2015; 12(10):811-824.
17. Frydrych AM. Dry mouth: Xerostomia and salivary gland hypofunction. Aust Fam Physician. 2016 Jul;45(7):488-92.
18. Gil-Montoya JA, Silvestre FJ, Barrios R, et al. Treatment of xerostomia and hyposalivation in the elderly: A systematic review. Med Oral Patol Oral Cir Bucal. 2016 May 1;21(3):e355-66.
19. Baer AN. Treatment of dry mouth and other non-ocular sicca symptoms in Sjögren's syndrome. In: UpToDate, Fox R, Romain PL (Eds), UpToDate, Waltham, MA. (Accessed on September 8, 2017.)
20. Baer AN. Treatment of dry mouth and other non-ocular sicca symptoms in Sjögren's syndrome. In: UpToDate, Fox R, Romain PL (Eds), UpToDate, Waltham, MA. (Accessed on August 8, 2018.)
21. Baer AN, Sankar V. Treatment of dry mouth and other non-ocular sicca symptoms in Sjögren's syndrome. In: UpToDate, Fox R, Romain PL (Eds), UpToDate, Waltham, MA. (Accessed on August 05, 2019.)
22. Baer AN, Sankar V. Treatment of dry mouth and other non-ocular sicca symptoms in Sjögren's syndrome. In: UpToDate, Fox R, Romain PL (Eds), UpToDate, Waltham, MA. (Accessed on July 9, 2020.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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