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Date Printed: October 17, 2017: 04:21 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-94010-08

Original Effective Date: 04/15/03

Reviewed: 03/28/13

Revised: 10/01/16

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Treatment of Hyperhidrosis

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

Hyperhidrosis may be defined as excessive sweating, beyond a level required to maintain normal body temperature in response to heat exposure or exercise.

Hyperhidrosis may be classified as:

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.

The second (T2) and third (T3) thoracic ganglia are responsible for palmar hyperhidrosis, the fourth (T4) thoracic ganglion controls axillary hyperhidrosis, and the first (T1) thoracic ganglion controls facial hyperhidrosis.

The consequences of hyperhidrosis are primarily psychosocial in nature. Excessive sweating may interfere with certain professions. For example, palmar hyperhidrosis may preclude artwork, working with electrical components, or playing certain musical instruments. In addition, hyperhidrosis may require several changes of clothing a day; excessive sweating may also result in staining of clothing or shoes.

A variety of therapies have been investigated for primary hyperhidrosis, including topical therapy with aluminum chloride, oral anticholinergic medications, iontophoresis, intradermal injections of botulinum toxin, endoscopic transthoracic sympathectomy, and surgical removal of axillary sweat glands.

Treatment of secondary hyperhidrosis focuses on treatment of the underlying cause, such as discontinuing certain drugs or hormone replacement therapy as a treatment of menopausal symptoms.

POSITION STATEMENT:

NOTE: For treatment of hyperhidrosis using botulinum toxin injections, please refer to MCG 09-J0000-29 Botulinum Toxin.

Lontophoresis, endoscopic transthoracic sympathectomy and/or surgical excision of sweat glands for treatment of primary hyperhidrosis meet the definition of medical necessity when ALL of the following criteria are met:

Treatment of hyperhidrosis is considered not medically necessary in the absence of functional impairment or medical complications.

Axillary liposuction as a treatment for primary hyperhidrosis is considered experimental or investigational, as there is insufficient clinical evidence to support conclusions regarding the effects of this therapy on health outcomes.

Chemical or surgical lumbar sympathectomy for the treatment of plantar hyperhidrosis is considered experimental or investigational due to the lack of peer reviewed literature demonstrating long term safety and efficacy and improvement in net health outcomes.

Microwave treatment as a treatment of any type of hyperhidrosis is considered experimental or investigational. There is insufficient clinical evidence in the peer-reviewed literature to support conclusions regarding long-term safety, efficacy or improvement in net health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to describe treatments for hyperhidrosis. There is no specific code describing surgical excision of the axillary sweat glands for hyperhidrosis.

CPT Coding:

32664

Thoracoscopy; with thoracic sympathectomy

97033

Iontophoresis, each 15 minutes

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Botulinum Toxins (L29088) and Therapy and Rehabilitation Services (L29289), located at fcso.com.

DEFINITIONS:

Aluminum chloride: a common component of over-the-counter antiperspirants, although a prescription product is available (Drysol). Although the mechanism is unclear, aluminum chloride is associated with atrophy of the secretory cells seen in eccrine sweat glands. Aluminum chloride is predominantly used to treat axillary hyperhidrosis and not palmar or volar hyperhidrosis.

Eccrine glands: any of the rather small sweat glands that produce a fluid secretion without removing cytoplasm from the secreting cells and that are restricted to the human skin (eccrine sweat gland).

Functional impairment: difficulties that substantially interfere with or limit role functioning in one or more major life activities (eg, may interfere with the ability to maintain appropriate hygiene, or may interfere with work in certain professions).

Gustatory: of or relating to the sense of taste. Gustatory hyperhidrosis conditions include Frey’s syndrome, encephalitis, syringomyelia, diabetic neuropathies, herpes zoster parotitis and parotid abscess.

Iontophoresis: a technique that involves the use of an electric current to introduce various ions through the skin.

Volar: relating to the palm of the hand or the sole of the foot; located on the same side as the palm of the hand.

RELATED GUIDELINES:

Botulinum Toxins, 09-J0000-29

OTHER:

Index terms:

Endoscopic sympathectomy
Gustatory hyperhidrosis
Hyperhidrosis

Iontophoresis

Sweating, excessive
Sympathectomy, thoracic
Thoracoscopic sympathectomy

REFERENCES:

  1. American Medical Association CPT (current edition).
  2. American Association of Neurological Surgery (AANS) Position Statement: Sympathectomy for hyperhidrosis. February 2007 [Reaffirmed Nov. 2009] Accessed at: http://www.aans.org on 02/19/13.
  3. Blue Cross Blue Shield Association Medical Policy 8.01.09 – Treatment of Hyperhidrosis (April 2012).
  4. Blue Cross Blue Shield Association TEC Assessment – Iontophoresis for Medical Conditions (06/03).
  5. Cerfolio RJ, De Campos JR, Bryant AS, Connery CP, Miller DL, DeCamp MM et al. The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis. Ann Thorac Surg. 2011 May;91(5):1642-8.
  6. ClinicalTrials.gov. A Study to Compare Oxybutynin to a Placebo in Women and the Effect on Plantar Hyperhidrosis. NCT01328015. Federal University of São Paulo. 04/01/11.
  7. ClinicalTrials.gov. Evaluation of Patients With Palmar Hyperhidrosis Submitted to Two Levels of Sympathectomy: T3 and T4. NCT01140659. University of São Paulo. 06/21/10.
  8. ClinicalTrials.gov. Histological Analysis Following Ulthera System Treatment for Hyperhidrosis. NCT01708551. Ulthera, Inc. 01/18/13.
  9. Coehlo et al. Bilateral Retroperitoneoscopic Lumbar Sympathectomy by Unilateral Access for Plantar Hyperhidrosis in Women. J Laparoendosc Adv Surg Tech A. 2010 Feb;20 (1):1-6.
  10. ECRI Institute. Endoscopic Thoracic Sympathectomy for the Treatment of Hyperhidrosis. Plymouth Meeting (PA): ECRI Institute Health Technology Assessment Information Service; 2006 Oct. (Evidence Report; no. 136).
  11. First Coast Service Options (FCSO) Local Coverage Determination #L29088, Botulinum Toxins (02/02/09).
  12. First Coast Service Options (FCSO) Local Coverage Determination #L29289, Therapy and Rehabilitation Services (02/02/09).
  13. First Coast Service Options (FCSO) Local Coverage Determination L31461, Autonomic Function Tests (01/23/11).
  14. Hayes Medical Technology Directory: Endoscopic Sympathectomy Treatment for Hyperhidrosis 01/14/03; updated 02/15/08.
  15. Hayes Search and Summary Report. Liposuction for Hyperhidrosis (08/16/07).
  16. Hong HC, Lupin M, O’Shaughnessy KF. Clinical Evaluation of a Microwave Device for Treating Axillary Hyperhidrosis. Dermatol Surg 2012;38:728–735.
  17. Hornberger J, Grimes K, Naumann M et al; Multi-Specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dematol 2004; 51(2):274-86.
  18. International Hyperhidrosis Society website; accessed 03/09/09.
  19. Kim et al. Chemical Lumbar Sympathetic Block in the Treatment of Plantar Hyperhidrosis: A Study of 69 Patients. Dermatol Surg. 2008 Oct;34(10):1340-5. Epub 2008 Jun 30.
  20. Krasna MJ. The Role of Surgical Treatment of Hyperhidrosis. Editorial: Mayo Clinic Proceedings. August 2011, Volume 86, Number 8.
  21. Loureiro et al. Endoscopic lumbar sympathectomy for women: effect on compensatory sweat. Clinics (Sao Paulo). 2008 Apr; 63(2): 189-96.
  22. Misiak P, Jabłoński S, Rzepkowska-Misiak B, Piskorz L, Brocki M, Wcisło S, Smigielski J, Kordiak J. Evaluation of the effectiveness of thoracic sympathectomy in the treatment of primary hyperhidrosis of hands and armpits using the measurement of skin resistance. Videosurgery Miniinv 2012; 7 (3): 147-155.
  23. 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.
  24. Rieger et al. Endoscopic lumbar sympathectomy for plantar hyperhidrosis. Br J Surg. 2009 Dec; 96(12): 1422-8.
  25. Rieger et al. Retroperitoneoscopic lumbar sympathectomy for the treatment of plantar hyperhidrosis: technique and preliminary findings. Surg Endosc. 2007 Jan; 21(1):1 29-35. Epub 2006 Sep 6.
  26. Schlereth T, Dieterich M, Birklein F. Hyperhidrosis—Causes and Treatment of Enhanced Sweating. Deutsches Ärzteblatt International 2009; 106(3): 32–7.
  27. Solish, Nowell MD, FRCPC, et al. "A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the canadian hyperhidrosis advisory committee". Dermatol Surg 33 (2007): 908-923.
  28. St. Anthony’s ICD-9-CM Code Book (current edition).
  29. Stefaniak T, Cwigon M, Laski D. In the Search for the Treatment of Compensatory Sweating. The Scientific World Journal Volume 2012, Article ID 134547.
  30. Stoleman, LP, MD, FACP< FRCP (C). Hyperhidrosis Medical and Surgical Treatment. Eplasty. 2008; 8: e22. Published online 2008 April 18.
  31. The Society of Thoracic Surgeons. Hyperhidrosis, Patient Information for Hyperhidrosis (accessed 03/09/09).
  32. The Society of Thoracic Surgeons. Expert Consensus for the Surgical Treatment of Hyperhidrosis. Ann Thorac Surg 2011;91:1642– 8.
  33. U.S. Food and Drug Administration (FDA). Center for Devices and Radiological Health (CDRH). MiraDry System (K103014), approved January 28, 2011. Accessed at http://www.accessdata.fda.gov/ on 02/20/13.
  34. U.S. Food and Drug Administration (FDA). Medical & Radiation Emitting Device Recalls: MiraDry System, Class II Recall (Z-2591-2011); recalled on June 27, 2011. Accessed at http://www.accessdata.fda.gov/ on 02/20/13.
  35. Wand F, Chen Y, Yang W, Shi L. Comparison of compensatory sweating and quality of life following thoracic sympathetic block for palmar hyperhidrosis: electrocautery hook versus titanium clip. Chinese Medical Journal 2011;124(21):3495-3498.
  36. Wolosker N, Milanez de Campos JR, et al. The use of oxybutynin for treating facial hyperhidrosis. An Bras Dermatol. 2011;86(3):451-6.
  37. Yosh ida et al. Chemical lumbar sympathectomy in plantar hyperhidrosis. Clin Auton Res. 2009 Dec 11. [Epub ahead of print].

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/28/13.

GUIDELINE UPDATE INFORMATION:

04/15/03

New Medical Coverage Guideline.

05/15/04

Scheduled review; added coverage statement for surgical excision of sweat glands for axillary hyperhidrosis; added investigational statement for axillary liposuction.

04/15/06

Scheduled review; no change in coverage statement; added cross-reference statement regarding Botox injections for treating hyperhidrosis; removed aluminum chloride from the list of treatments discussed in this MCG; added “refractory to standard medical treatment” to the coverage statement in When Services Are Covered.

04/15/07

Scheduled review; no change in coverage statement.

06/15/07

Reformatted guideline.

04/15/08

Scheduled review; no change in position statement. Updated references.

04/15/09

Scheduled review. Update references and position statement with addition of indication for the use of Botox.

04/15/10

Annual review; investigational position statement for chemical or surgical lumbar sympathectomy added to guideline. References updated.

10/15/10

Revision; related ICD-10 codes added.

04/15/12

Scheduled review. Position statement maintained. Revised description section, ICD10 coding and definitions. Updated references.

04/15/13

Scheduled review. Revised description and position statement (designated microwave treatment for hyperhidrosis as experimental or investigational). Revised ICD9 coding, definitions and index terms. Updated references and reformatted guideline.

02/15/14

Revision; Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Revision: Billing/Coding Information section updated.

Date Printed: October 17, 2017: 04:21 PM