Treatment of Hyperhidrosis (Medicaid Expansion)

Policy ID: ME-S-178-028-01

Section: Surgery

Effective Date: December 09, 2024

Last Reviewed: November 19, 2024

Applies To: Medicaid Expansion Only

Description

Hyperhidrosis is excessive sweating that affects the individual's quality of life, resulting in social and work impairment and emotional distress. Primary hyperhidrosis is bilaterally symmetric, focal, excessive sweating of the axillae, palms, soles, or craniofacial region not caused by other underlying conditions. Secondary hyperhidrosis may be focal or generalized, and is caused by an underlying medical condition or medication.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Treatment for primary focal hyperhidrosis may be considered medically necessary when 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% 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.

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 palmer hyperhidrosis will expire in three (3) months from the original authorization date for any diagnosis.

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.

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

64653

69676

97033

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.

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

Covered Diagnosis code for Procedure Codes: J0585, 97033, 64650, 32664

L74.510

Covered Diagnosis code for Procedure Codes: J0585, 97033, 64653, 32664

L74.512

Covered Diagnosis code for Procedure Codes: 97033, J0585

L74.513

Covered Diagnosis code for Procedure Codes: 32664, J0585

L74.511

Covered Diagnosis code for Procedure Code: 69676

L74.52

Covered Diagnosis code for Procedure Code: 64653

L74.512

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2024 Effective December 09, 2024

Adopted Medicaid Expansion specific policy

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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Medical Policies Quick Search

Treatment of Hyperhidrosis (Medicaid Expansion)

Description

Policy Application

Criteria

Procedure Codes

Axillary Region

Procedure Codes

Palmar Region

Procedure Codes

Plantar Region

Procedure Codes

Craniofacial Region

Procedure Codes

Secondary Hyperhidrosis: Secondary Gustatory Hyperhidrosis

Procedure Codes

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

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer