Treatment of primary hyperhidrosis (705.21), including botulinum toxin type A, BOTOX® (J0585), endoscopic transthoracic sympathectomy (32664), and surgical excision of axillary sweat glands (11450-11451) is considered eligible for patients with focal, visible and excessive sweating of at least six months duration without apparent cause that includes all of the following characteristics:

• Sweating is bilateral and relatively symmetrical
• Sweating significantly impairs daily activities
• Episodes occur at least once per week
• The age of onset is less than 25 years
• Focal sweating stops during sleep

The patient must be classified as “severe” or a “4” on the Hyperhidrosis Disease Severity Scale prior to treatment for hyperhidrosis.  This is a four-point scale that includes the following:

1 – sweating is never noticeable and never interferes with daily activities
2 – sweating is tolerable but sometimes interferes with daily activites
3 – sweating is barely tolerable and frequently interferes with daily activities
4 – sweating is intolerable and always interferes with daily activities.

The patient must have documented treatment with 10-35% aluminum chloride of at least six months duration that failed to reduce the severity index scale before the initiation of botulinum toxin, endoscopic transthoracic sympathectomy or surgical excision of axillary sweat glands.

In the absence of the above criteria elements, treatment for primary hyperhidrosis is considered not medically necessary, and is not covered. 

Eligibility of botulinum toxin type A, BOTOX® (J0585), in the treatment of hyperhidrosis is limited only to treatment for primary axillary hyperhidrosis that has been inadequately managed with topical agents. The use of BOTOX for treatment of palmar, plantar, or facial hyperhidrosis or for primary axillary hyperhidrosis in the absence of the above criteria elements is considered not medically necessary, and is not eligible for coverage.

Services that do not meet the criteria listed above will be considered not medically necessary. Effective January 26, 2009, a participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Iontophoresis (97033) and axillary liposuction (17999) are considered experimental/ investigational as treatment for primary hyperhidrosis (705.21).  As such, iontophoretic devices used in the home for treatment of primary hyperhidrosis are not covered. The medical efficacy for iontophoresis and axillary liposuction has not been established.  These procedures are not eligible for reimbursement or payment.  A participating, preferred, or network provider can bill the member for these procedures.

See Medical Policy Bulletin I-11 for additional guidelines on the use of botulinum toxin.

Description

Hyperhidrosis is defined as excessive perspiration, beyond a level required to maintain normal body temperature in response to heat exposure, physical exertion, or exercise.  Hyperhidrosis can be classified as either primary or secondary.  Primary hyperhidrosis is idiopathic in nature, typically involving the hands (palmar), feet (plantar), or axillae (underarms).  Secondary hyperhidrosis can result from a variety of drugs,[e.g., tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs)], or underlying diseases/conditions, such as febrile diseases, diabetes mellitus, or menopause.  Gustatory hyperhidrosis causes facial hyperhidrosis in response to hot or spicy foods, resulting from surgery to the parotid gland and subsequent aberrant regenerating parasympathetic fibers.

The consequences of hyperhidrosis are primarily psychosocial in nature.  Excessive perspiration may be socially embarrassing (e.g., limiting the ability to shake hands) or 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 daily and may cause staining of clothing and/or shoes.

Treatment of secondary hyperhidrosis (705.22) naturally focuses on treatment of the underlying cause, such as discontinuing certain drugs or providing hormone replacement therapy as a treatment of menopausal symptoms.   

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employees Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious life-threatening condition and when medically necessary and appropriate for the patient's condition. Iontophoresis, iontophoretic devices and axillary liposuction are considered eligible in the treatment of hyperhidrosis when determined medically necessary based upon the patient's condition.

Treatment of Hyperhidrosis, Medical Policy Reference Manual, Policy 8.01.19, 02/25/04.