Criteria
Treatment for primary focal hyperhidrosis may be considered medically necessary when any ONE(1) of the following criteria have been met:
- History of recurrent skin maceration with bacterial or fungal infections (including, but not limited to, cutaneous disorders such as dermatophytosis (ringworm), pitted keratolysis, and/or 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
BOTH of the following criteria must be met:
- 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 percent aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash.
Treatment of Hyperhidrosis not meeting the criteria as indicated in this policy will be considered not medically necessary
Procedure Codes
17999
|
32664
|
64650
|
64653
|
69676
|
97033
|
J0585
|
Any ONE of the following treatments outlined below may be considered medically necessary for the corresponding focal region ONLY when the general criteria outlined above has been met.
Axillary Region
- Botulinum Toxin A (OnabotulinumotoxinA) for severe primary axillary hyperhidrosis that is inadequately managed with topical agents, in individuals 18 years and older; or
- Iotophoresis; 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 three (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, radiofrequency ablation and microwave treatment for axillary hyperhidrosis are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature
Treatment of axillary hyperhidrosis not meeting the criteria as indicated in this policy will be considered not medically necessary.
Procedure Codes
17999
|
32664
|
64650
|
97033
|
J0585
|
Any ONE (1) of the following treatments may be considered medically necessary for the corresponding focal region ONLY when the general criteria outlined above have been met.
Palmar Region
- Botulinum Toxin A (OnabotulinumtoxinA) for severe primary palmar hyperhidrosis that is inadequately managed with topical agents, in individuals 18 years and older; or
- Iontophoresis; or
- Endoscopic transthoracic sympathectomy (ETS), if conservative treatment (i.e., aluminum chloride or botulinum toxin type A, individually and in combination) has failed.
Initial authorization for botulinum toxin A (OnabotulinumtoxinA) for palmer hyperhidrosis will expire in three (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.
Treatment of palmar hyperhidrosis not meeting the criteria as indicated in this policy will be considered not medically necessary.
Procedure Codes
| 17999 |
32664 |
64653 |
64999 |
97033 |
J0585 |
Any ONE (1) of the following treatments may be considered medically necessary for the corresponding focal region ONLY when the general criteria outlined above have been met.
Plantar Region
- Botulinum toxin A (OnabotulinumtoxinA) for severe primary plantar hyperhidrosis that is inadequately managed with topical agents, in individuals 18 years and older; or
- Iontophoresis.
Initial authorization for botulinum toxin A (OnabotulinumtoxinA) for plantar hyperhidrosis will expire in three (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.
Treatment of plantar hyperhidrosis not meeting the criteria as indicated in this policy will be considered not medically necessary.
Procedure Codes
17999
|
64653
|
64818
|
97033
|
J0585
|
Any ONE (1) of the following treatments may be considered medically necessary for the corresponding focal region ONLY when the general criteria outlined above have been met.
Craniofacial Region
- Botulinum toxin A (OnabotulinumtoxinA) for severe primary craniofacial hyperhidrosis that is inadequately managed with topical agents, in individuals 18 years and older; or
- ETS, if conservative treatment (e.g., aluminum chloride) has failed.
Initial authorization for botulinum toxin A (OnabotulinumtoxinA) for Craniofacial hyperhidrosis will expire in three (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.
Treatment of craniofacial hyperhidrosis not meeting the criteria as indicated in this policy will be considered not medically necessary.
Procedure Codes
17999
|
32664
|
64653
|
97033
|
J0585
|
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:
- Surgical options (e.g., Tympanic neurectomy), if conservative treatment has failed.
Treatment of secondary hyperhidrosis not meeting the criteria as indicated in this policy will be considered not medically necessary.
Procedure Codes
NOTE: Microwave treatment, lumbar sympathectomy and radiofrequency ablation are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of these services cannot be established by the available published peer-reviewed literature.
Diagnosis Codes
Covered Diagnosis code for Procedure Codes: J0585, 97033, 64650, 32664
Covered Diagnosis code for Procedure Codes: J0585, 97033, 64653, 32664
Covered Diagnosis code for Procedure Codes:97033, J0585
Covered Diagnosis code for Procedure Codes:32664, J0585
Covered Diagnosis code for Procedure Code:69676
Covered Diagnosis code for Procedure Code: 64653
