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.
Treatment for primary focal hyperhidrosis may be considered medically necessary when ANY ONE of the following general criteria have been met:
AND
In addition to ANY ONE of the above criteria, BOTH of the following criteria must be met to be considered medically necessary:
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
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
Botulimnum toxin B (RimabotulinumtoxinB), microwave treatment and radiofrequency ablation for palmar hyperhidrosis are considered experimental/investigational, and therefore non-covered.
Plantar Region
Botulinum toxin, lumbar sympathectomy and microwave treatment for plantar hyperhidrosis are considered experimental/investigational, and therefore non-covered.
Craniofacial Region
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:
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.
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 |
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
