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Medical Policy: 08.01.08
Original Effective Date: January 2002
Reviewed: November 2011
Revised: November 2011
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Hyperhidrosis is excessive sweating, beyond a level required to maintain normal body temperature in response to heat exposure or exercise. Hyperhidrosis can be classified as either primary or secondary.
Primary focal hyperhidrosis is idiopathic in nature and is defined as excessive sweating induced by sympathetic hyperactivity in selected areas that is not associated with an underlying disease process. The most common locations are underarms (axillary hyperhidrosis), palms (palmar hyperhidrosis), soles (plantar hyperhidrosis) or face (craniofacial hyperhidrosis).
Primary focal hyperhidrosis is a condition that is characterized by visible, excessive sweating of at least 6 months’ duration without apparent cause and with at least two of the following features:
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bilateral and relatively symmetric sweating,
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impairment of daily activities, frequency of at least once per week,
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age at onset younger than 25 years,
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positive family history,
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cessation of focal sweating during sleep
Secondary hyperhidrosis can result from a variety of drugs, such as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), or underlying diseases/conditions, such as febrile diseases, diabetes mellitus, or menopause. Secondary hyperhidrosis is usually generalized or craniofacial sweating. Secondary gustatory hyperhidrosis is excessive sweating on ingesting highly spiced foods. This trigeminovascular reflex typically occurs symmetrically on scalp or face and predominately over forehead, lips, and nose. Secondary facial gustatory sweating, in contrast, is usually asymmetrical and occurs independently of the nature of the ingested food. This phenomenon frequently occurs after injury or surgery in the region of the parotid gland. Frey’s syndrome is an uncommon type of secondary gustatory hyperhidrosis that arises from injury to or surgery near the parotid gland resulting in damage to the secretory parasympathetic fibers of the facial nerve. After injury, these fibers regenerate and miscommunication occurs between them and the severed postganglionic sympathetic fibers that supply the cutaneous sweat glands and blood vessels. The aberrant connection results in gustatory sweating and facial flushing with mastication. Aberrant secondary gustatory sweating follows up to 73% of surgical sympathectomies and is particularly common after bilateral procedures.
A variety of therapies have been investigated for primary hyperhidrosis, including topical therapy with aluminum chloride, iontophoresis, intradermal injections of botulinum toxin type A, endoscopic transthoracic sympathectomy, and surgical excision of axillary sweat glands. Thoracic sympathectomy is an invasive procedure intended to arrest the symptoms of hyperhidrosis. T2 sympathectomy is performed for patients with palmar hyperhidrosis and may significantly reduce foot sweating as well; while T3 and T4 sympathectomies are performed for those with axillary hyperhidrosis. The procedures can be performed with either conventional electrocautery or laser. Treatment of secondary hyperhidrosis focuses on the treatment of the underlying cause, such as discontinuing certain drugs or hormone replacement therapy as a treatment of menopausal symptoms.
The outcome of different surgical and medical treatment modalities is best assessed by using a combination of tools. Quantitative tools include gravimetry, evaporimetry, and Minor's starch and iodine test. Qualitative assessment tools include general health surveys and hyperhidrosis -specific surveys. Of these, the Hyperhidrosis Disease Severity Scale (HDSS) has been found to have a good correlation to other assessment tools and to be practical in the clinical setting.
In the hyperhidrosis disease severity scale, patients rate the severity of symptoms on a scale of 1-4:
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My underarm sweating is never noticeable and never interferes with my daily activities.
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My underarm sweating is tolerable but sometimes interferes with my daily activities.
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My underarm sweating is barely tolerable and frequently interferes with my daily activities.
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My underarm sweating is intolerable and always interferes with my daily activities.
Other indications for botulinum toxin are discussed separately in policy:
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Prior Approval:
Not applicable
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Policy:
In a small subset of patients, treatment of primary hyperhidrosis may be considered medically necessary with the following medical complications:
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acrocyanosis of the hands;
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history of recurrent skin maceration with bacterial or fungal infections;
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history of recurrent secondary infections;
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history of persistent eczematous dermatitis in spite of medical treatments with topical dermatological or systemic anticholinergic agents.
Primary Axillary Hyperhidrosis
The following treatments may be considered medically necessary:
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Aluminum chloride 20% solution
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For patients 18 years of age and older, intradermal botulinum toxin for severe symptoms inadequately managed with topical agents
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Endoscopic transthoracic sympathectomy and surgical excision of axillary sweat glands in patients failing 1 year of conservative treatment (i.e., aluminum chloride or botulinum type A, as monotherapy or in combination)
The following treatments are considered investigational, including but not limited to:
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axillary liposuction
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iontophoresis
Primary Palmar Hyperhidrosis
The following treatments may be considered medically necessary:
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Aluminum chloride 20% solution
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For patients 18 years of age and older, intradermal botulinum type A for severe symptoms inadequately managed with topical agents
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Endoscopic transthoracic sympathectomy in patients failing 1 year of conservative treatment (i.e., aluminum chloride or botulinum type A, as monotherapy or in combination)
The following treatments are considered investigational, including but not limited to:
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botulinum type B
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iontophoresis
Primary Plantar Hyperhidrosis
The following treatment may be considered medically necessary:
The following treatments are considered investigational, including but not limited to:
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botulinum type A
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botulinum type B
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iontophoresis
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lumbar sympathectomy
Primary Craniofacial Hyperhidrosis
The following treatments may be considered medically necessary:
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Aluminum chloride 20% solution
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Endoscopic transthoracic sympathectomy in patients failing 1 year of conservative treatment (i.e., aluminum chloride 20% solution)
The following treatments are considered investigational, including but not limited to:
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botulinum type A
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botulinum type B
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iontophoresis
Secondary Gustatory Hyperhidrosis
The following treatments may be considered medically necessary
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Aluminum chloride 20% solution*
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Surgical options (i.e., tympanic neurectomy), if conservative treatment has failed.
The following treatments are considered investigational as a treatment for severe gustatory hyperhidrosis including, but not limited to:
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botulinum toxins type A and type B are considered investigational for treatment of gustatory hyperhidrosis as a result of Frey’s syndrome and other conditions that effect gustatory stimuli including, but not limited to: encephalitis, syringomyelia, diabetic neuropathies, herpes zoster parotitis, and parotid abscess
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iontophoresis
Treatment of primary hyperhidrosis with thoracic sympathectomy in patients not meeting the above criteria is considered not medically necessary.
Treatment of all forms of hyperhidrosis with any method described above in patients who do not meet the criteria described above is considered not medically necessary.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 32664 Thoracoscopy, surgical; with thoracic sympathectomy
- 64650 Chemodenervation of eccrine glands; both axillae
- 64653 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day
- J0585 Botulinum toxin type A, per unit
- J0587 Botulinum toxin type B, per 100 units
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Selected References:
- Rajesh YS, Pratap CP, Woodyer AB. Thoracoscopic sympathectomy for palmar hyperhidrosis and Raynaud’s phenomenon of the upper limb and excessive facial blushing: a five year experience. Postgrad Med J 2002;78:682-684.
- Leseche G, Castier Y, Thabut G, et al. Endoscopic transthoracic sympathectomy does not reduce postoperative compensatory sweating. Journal of Vascular Surgery, January 2003.
- Atkinson JLD, Fealy RD, Sympathotomy Instead of Sympathectomy for Palmar Hyperhidrosis: Minimizing Postoperative Compensatory Hyperhidrosis. Mayo Clinic Proc. 2003;78:167-172.
- Lin TS, KUO SJ, Chou MC. Uniportal Endoscopic Thoracic Sympathectomy For Treatment of Palmar and Axillary Hyperhidrosis: Analysis of 2000 Cases. Neurosurgery 51 [Suppl 2]:84-87, 2002.
- Shelley WB, Talanin NY, Shelley ED. Botulinum toxin therapy for palmar hyperhidrosis. Journal of the American Academy of Dermatology 1998;38:227-229.
- Sevim S, Dogu O, Kaleagasi H. Botulinum toxin-A therapy for palmar and plantar hyperhidrosis. Acta Neurol Belg. 2002 Dec;102(4):167-70.
- Vadoud-Seyedi J. Treatment of plantar hyperhidrosis with botulinum toxin type A. Int J Dermatol. 2004 Dec;43(12):969-71.
- ECRI. Endoscopic Thoracic sympathectomy for Palmar hyperhidrosis. Plymouth meeting (PA): ECRI Health Technology Information Service; 2004 July 9. 15p. (ECRI Hotline Response).
- ECRI. Iontophoresis for Hyperhidrosis. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2004 July 22. 7p. (ECRI Hotline Response).
- ECRI. Botulinum Toxin for Treatment of Hyperhidrosis. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2003 Sept. 40 p. Windows on Medical Technology; No. 99.
- Baumgartner FJ, Toh Y. Severe hyperhidrosis: clinical features and current thoracoscopic surgical management. Ann Thorac Surg. 2003;76(6):1878-83.
- Leseche G. Castier Y, Thabut G et al. Endoscopic transthoracic sympathectomy for upper limb hyperhidrosis: limited sympathectomy does not reduce postoperative compensatory sweating. J Vasc Surg. 2003;37(1):124-8.
- Naumann M, So Y, Argoff CE et al. Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2008;70;1707-1714.
- ECRI. Iontophoresis for Hyperhidrosis. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 March 23. (ECRI Hotline Response). Also available: http://www.ecri.org.
- ECRI. Endoscopic Thoracic Sympathectomy for Palmar Hyperhidrosis. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 January 27. (ECRI Hotline Response). Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
October 2010 Annual review Policy renewed
November 2011 Annual review Policy revised
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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