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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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:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    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:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    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.