Description

Hyperhidrosis is the secretion of sweat in the 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.

Criteria

General medical necessity criteria for the treatment of primary focal hyperhidrosis.

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, 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 above will be considered not medically necessary.

Procedure Codes

Criteria for specific focal regions

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

Axillary Region

• Botulinum Toxin A (Onabotulinumotixin A) 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 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 (Onabotulinumtoxin A).

Procedure codes

Axillary liposuction, radiofrequency ablation and microwave treatment for axillary hyperhidrosis are considered experimental/investigational and therefore non-covered.  Scientific evidence does not demonstrate the effectiveness of these treatments.

Treatment of axillary hyperhidrosis not meeting the criteria above will be considered not medically necessary.

Procedure codes

Palmar Region

• Botulinum Toxin A (Onabotulinumtoxin A) for severe primary palmar hyperhidrosis that is inadequately managed with topical agents, in individuals 18 years and older; or

Note: Injections should occur no sooner than 6 months apart.

• Iontophoresis; or
• ETS, if conservative treatment (i.e., aluminum chloride or botulinum toxin type A, individually and in combination) has failed.

Procedure Codes

Botulinum toxin B (Rimabotulinumtoxin B), microwave treatment, and radiofrequency ablation for palmar hyperhidrosis are considered experimental/investigational and therefore non-covered.  Scientific evidence does not demonstrate the effectiveness of these treatments.

Treatment of palmar hyperhidrosis not meeting the criteria above will be considered not medically necessary.

Procedure Codes

Plantar Region

• Iontophoresis.

Procedure Codes

Botulinum toxin, lumbar sympathectomy, radiofrequency ablation, and microwave treatment for plantar hyperhidrosis are considered experimental/investigational and therefore non-covered.  Scientific evidence does not demonstrate the effectiveness of these treatments.

Treatment of plantar hyperhidrosis not meeting the criteria above will be considered not medically necessary.

Procedure Codes

Craniofacial Region

• ETS, if conservative treatment (e.g., aluminum chloride) has failed.

Procedure Codes

Botulinum toxin, iontophoresis, radiofrequency ablation, and microwave treatment for craniofacial hyperhidrosis are considered experimental/investigational and therefore non-covered. Scientific evidence does not demonstrate the effectiveness of these treatments.

Treatment of craniofacial hyperhidrosis not meeting the criterial above will be considered not medically necessary.

Procedure Codes

Secondary Hyperhidrosis:  Secondary Gustatory Hyperhidrosis

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

• Surgical options (e.g., Tympanic neurectomy, if conservative treatment has failed.

Procedure Codes

Botulinum toxin and iontophoresis for severe gustatory hyperhidrosis are considered experimental/investigational and therefore non-covered.  Scientific evidence does not demonstrate the effectiveness of these treatments.

Treatment of secondary hyperhidrosis not meeting the criteria above will be considered not medically necessary.

Procedure Codes

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes: J0585          

Covered Diagnosis codes for Procedure Codes: 64650

Covered Diagnosis codes for Procedure Codes: 64653     

Covered Diagnosis codes for Procedure Codes: 97033

Covered Diagnosis codes for Procedure Codes: 32664

Covered Diagnosis for Procedure Codes: 69676

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