HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-178-023
Topic:
Treatment of Hyperhidrosis
Section:
Surgery
Effective Date:
March 18, 2019
Issued Date:
March 18, 2019
Last Revision Date:
March 2019
Annual Review:
July 2018
 
 

Hyperhidrosis is the secretion of sweat in amounts greater than physiologically needed for thermoregulation.

It is most commonly a chronic idiopathic (primary) condition; however, secondary medical conditions or medications should be excluded.

Policy Position

Treatment for primary focal hyperhidrosis may be considered medically necessary when ANY ONE of the following general criteria have been met:

  • Acrocyanosis of the hands; or
  • History of recurrent skin maceration with bacterial or fungal infections, (including but not limited to cutaneous disorders such as dermatophytosis (ringworm), pitted keratolysis, viral warts at the sites of hyperhidrosis); or
  • History of atopic dermatitis (atopic eczema) in spite of medical treatments with topical dermatological or systemic anticholinergic agents.

AND

In addition to ANY ONE of the above criteria, BOTH of the following criteria must be met to be considered medically necessary:

  • Unresponsive to or unable to tolerate pharmacotherapy modalities prescribed for excessive sweating (including but not limited to anti-cholinergics, beta-blockers, or benzodiazepines); and
  • Topical 20% aluminum chloride or other extra strength antiperspirants are ineffective or result in a severe rash.

ANY ONE of the following treatments outlined below may be considered medically necessary for the corresponding focal regions when the criteria outlined above has been met.

 Axillary Region

  • Aluminum Chloride 20% Solution; or
  • Botulinum toxin A (OnabotulinumtoxinA) for severe primary axillary hyperhidrosis that is inadequately managed with topical agents, in patients 18 years and older; or
  • Iontophoresis; or
  • Endoscopic transthoracic sympathectomy (ETS) and surgical excision of axillary sweat glands, if conservative treatment (i.e., aluminum chloride or botulinum toxin, individually and in combination) has failed. 

NOTE: Sympathectomy for hyperhidrosis treatment of axillary and palmar regions requires an inpatient stay. 

Initial authorization for botulinum toxin A (OnabotulinumtoxinA) for axillary hyperhidrosis will expire in 3 months from the original authorization date for any diagnosis. Additional authorization may be given if documentation of an objective measurable effect is provided indicating clinical improvement of the condition. Absence of clinical improvement of axillary hyperhidrosis will be considered not medically necessary for further injections of botulinum toxin A (OnabotulinumtoxinA) 

Axillary liposuction and microwave treatment for axillary hyperhidrosis are considered experimental/investigational, and therefore non-covered.

Axillary liposuction as treatment for primary hyperhidrosis is considered experimental/investigational, and therefore non-covered.

Palmar Region

  • Aluminum Chloride 20% Solution; or
  • Botulinum toxin A (OnabotulinumtoxinA) for severe primary palmar hyperhidrosis that is inadequately managed with topical agents, in patients 18 years and older; or

    NOTE: Injections should occur no sooner than 6 months apart.
  • Iontophoresis; or
  • Endoscopic transthoracic sympathectomy (ETS), if conservative treatment (i.e., aluminum chloride or botulinum toxin type A, individually and in combination) has failed. 

Botulimnum toxin B (RimabotulinumtoxinB), microwave treatment and radiofrequency ablation for palmar hyperhidrosis are considered experimental/investigational, and therefore non-covered. 

Plantar Region

  • Aluminum Chloride 20% Solution; or
  • Iontophoresis.

Botulinum toxin, lumbar sympathectomy and microwave treatment for plantar hyperhidrosis are considered experimental/investigational, and therefore non-covered.

Craniofacial Region

  • Aluminum Chloride 20% Solution; or 
  • Endoscopic transthoracic sympathectomy (ETS), if conservative treatment (e.g., aluminum chloride) has failed. 

Botulinum toxin, iontophoresis, and microwave treatment for craniofacial hyperhidrosis are considered experimental/investigational, and therefore non-covered.


Secondary Hyperhidrosis: Secondary Gustatory Hyperhidrosis
The following treatments may be considered medically necessary for the treatment of severe gustatory hyperhidrosis when the above general criteria have been met:

  • Aluminum Chloride 20% Solution; or 
  • Surgical options (e.g., tympanic neurectomy, if conservative treatment has failed. 

Botulinum toxin and iontophoresis for severe gustatory hyperhidrosis are considered experimental/investigational, and therefore not covered.

15877

15878

17999

32664

64650

64653

64818

69676

97033

J0585

J0587

 

 

 




Treatment of hyperhidrosis is considered not medically necessary in the absence of functional impairment or medical complications, and therefore non-covered.


Related Policies

Refer to medical policy I-11 Botulinum Toxin (Chemodenervation) for additional information.


Covered Diagnosis codes for Procedure Codes: 32664, 64650, 64653, 69676, 97033, J0585

L74.52

L74.510

L74.511

L74.512

L74.513

L74.519

R61

Covered Diagnosis Code for Procedure Code: J0587

L74.512

 

 

 

 

 

 

Non-Covered Diagnosis codes for Procedure Codes 15877, 15878, 17999

L74.52

L74.510

L74.511

L74.512

L74.513

L74.519

 



Place of Service: Inpatient/Outpatient

Treatment of Hyperhidrosis is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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